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Chamber Music Clinic Entry Form
Deadline: May 1

Use the tab key or mouse to move between answer fields. Using the Enter key will submit your form.
Name of GroupName to be printed
Number of students in ensemble
Title of Selection
Composer
Performance Duration
Please print ensemble name as it should be printed on the program. Submit only one chamber music group per form.
Student Information
1st Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
2nd Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
3rd Student`s Name
Is this student participating in Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
4th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
5th Student`s Name
Is this student participating in Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
6th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
7th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
8th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
9th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another Student?
Yes
No
10th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another Student?
Yes
No
11th Student`s Name
Is this student participating in Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another Student?
Yes
No
12th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
13th Student`s Name
Is this student participating in Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
14th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
Add another student?
Yes
No
15th Student`s Name
Is this student participating in SA Ensemble or Performance?
Address
City
State
Zip Code
Phone Number
Email (parent`s or student`s)
Age
School Grade
Instrument
Teacher Name
If you need to add more participants, please submit another form with the same group name.
Sponsor Information
Name
Address
City
State
Zip Code
Cell and Home Numbers
Phone Number
Email confirmation of receipt of this form will be sent to the email address listed below.
*Email
Are you a TMTA Member?
Yes
No
Association
NCTM
Relationship to Ensemble
Please explain
I understand that as the sponsoring adult (teacher/coach/parent), I will be responsible for the group, will provide an adult sponsor/chaperone in attendance for the group, and serve as contact between the Chamber Music Clinic Chair and the group. Communication will be done by email.
Do you agree to be responsible?
I agree to be responsible for the group.
I do not agree.
If you are unable to agree with the statement above, a different sponsor should be found and submitted. This group will not be registered until a responsible sponsor is designated.
Ensemble Coach Information
Name
Address
City
State
Zip Code
Cell and Home Numbers
Phone Number
Email
Are you a TMTA Member?
Yes
No
Association
Fees
Fees are based on the duration of the selection performed.
Duration of selection
 
Non-member fees of $12 each should be added for each participant whose teacher is not a TMTA member.
Additional fees
Non-member fees
Scheduling
List any other convention activities for this student. Include times, if known.

If you are listing Convention Ensemble and you do not yet know your scheduled rehearsal and/or performance times, please include the name of the piece you are playing.
Convention Conflicts
Other performance opportunities
We are interested in other performance opportunities.
We are only interested in the performance clinic.
Additional Instructions
Use one form per ensemble group unless the group is too large to list all the members on one form. In that case, use additional forms.
You may return to the form using the link provided on the confirmation page. You will also receive an emailed confirmation for each submitted form.
Payment must be made by the deadline using the Convention Student Activities Payment Form. Fees may be paid by check or credit card.

You may include all of your students participating in any of the convention activities in one payment form. You do NOT need to mail in copies of student entry form confirmations.
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