2008 Application

Cumberland Valley School of Gospel Music

Please Print and Mail, along with non-refundable registration fee, to

CVSGM, Inc., Sam Oldham, 109 Choctaw, Dr., Hendersonville, TN 37075

Name______________________________________________________________________________________

                    Last                               First                          Middle Initial                 Name You Wish to Be Called

Address___________________________________________________________________________________

                          Street                                                 City                                            State                        Zip

E-Mail Address_____________________________________________________________________________

Date of Birth______________________________________________ Age______ Male _____ Female _____

Parents/Guardians' Name_____________________________________________________________________

Phone (______) ___________________________ Alternate Phone (______) ____________________________

Other Emergency Contact Person_______________________________________________________________

Relationship to Student______________________________________ Phone Number (____) _______________

List Allergies_______________________________________________________________________________

Doctor and Phone___________________________________________________________________________

Do you plan to (please check )      ____Live on Campus       ___Commute Daily       ___Attend Night Classes

                                                            ____Both Weeks             ___First Week Only      ___Second Week Only

If You Live on Campus, Roommate Preference________________________________________

PRIVATE LESSONS - Five 30-minute lessons, Additional $60 (Please check lessons desired)

_____Piano _____Voice _____Quartet/Trio Training _____Songwriting _____Fiddle _____Guitar _____Mandolin _____Banjo _____Dulcimer _____Electric Bass Guitar

                                                                                      Teacher Preference_______________________________

Student Signature____________________________________________________ Date__________________

Emergency Release

In the event of illness or accident which requires medical treatment, at a time when a parent or legal guardian cannot be located or contacted in a timely fashion, I give permission for CVSGM and representatives thereof to secure medical emergency treatment and do hereby give permission to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection or surgery for my child, ___________________________. I will not hold CVSGM, its representatives, or the medical personnel liable. This is done with the understanding that every attempt will have been made to contact a parent or other authorized person/guardian.

Parent/Guardian's Signature______________________________________________ Date_____________

IMPORTANT: PARENT/GUARDIAN MUST SIGN APPLICATION OF MINOR BELOW 18 YEARS OF AGE.

THE NON-REFUNDABLE REGISTRATION FEE AND A COPY OF HEALTH INSURANCE COVERAGE FOR STUDENT MUST BE ENCLOSED WITH THE APPLICATION.

Students are accepted without regard to race, creed, or national origin. Enrollment limited due to space available.