2019 Chandler Starr Miller Scholarship Competition - Registration Form

Scholarship Competition: Saturday, February 23, 2019 (MPAC Campus)
Winners' Recital: Sunday, February 24, 2019 at 2:00 pm

Please Review the 2018-2019 Rule Book before registration. 

To register and pay online, please complete the form below and click on "Submit" to register. To submit this form, all "*" fields must be filled in.

To register via mail or in person, please contact the Mendelssohn Office at 815-964-9713. 

$35.00
STUDENT/REGISTRANT INFORMATION:
Student First Name*
Student Last Name*
Student Address*
City*
State*
Zip*
Student Phone*
Student Mobile Phone
Student Email (or parent email if student doesn't have one)*
Confirm Email*
School Name
Grade*
Age at Competition*
Instrument*
Division*
Years studied on instrument*
Entered in another division?
List composition(s), name of movement, composer, and book name and/or publisher
1st Piece:*
2nd Piece
PARENT OR GUARDIAN INFORMATION:
Name
Full Address
Parent/Guardian Phone
Parent/Guardian Email
TEACHER INFORMATION:
Name*
Street Address*
City
Teacher Phone*
Teacher Email*
ACCOMPANIST INFORMATION:
Name
Full Address
Accompanist Phone
Accompanist Email
PAYMENT INFORMATION:
Card Type*
Card Number*
Expiration Month*
Expiration Year*
Card Security Code*
Name on Card (Parent/Guardian)*
MEDIA RELEASE CONSENT:
I authorize the Mendelssohn Performing Arts Center to use photographs, voice recordings or videotaped images of the undersigned individual for any of its commercial or non-commercial purposes, including promoting, publicizing, or explaining the MPAC.
These images may be displayed in a wide variety of formats, including but not limited to: print, broadcast, videotape, CD-ROM, electronic/online media (including but not limited to Facebook and YouTube), and the MPAC’s e-newsletter, e-blasts, and website.
This authorization may be revoked at any time by written declaration from the undersigned individual (or in the case of a minor, from the parent/guardian) or his or her authorized representative.
I acknowledge and agree that any such revocation will only operate prospectively as of the date of the written declaration.
Please Check One:*
I understand that by withholding permission (choosing No), any group photo including my student will not be used for marketing.
SIGNATURE / PARENTAL CONSENT:
Electronic signature on this form indicates the parent/guardian (or self if Adult) gives permission for the student to participate in the competition. This form must be signed by the parent/guardian (or self if Adult) and submitted in order to register.
Electronic Signature (type name):*

Mendelssohn Performing Arts Center is a 501(c)3 non-profit organization.



REGISTRATION FEE:

Student Fee: $35 per division. Separate entry forms must be completed for each division entered.

Teacher Fee: None.


DEADLINE:

All online registrations must be received by no later than 11:59 p.m. on Sunday, December 16, 2018.

Paper registrations must be received by no later than 5:00 p.m. on Friday, December 14, 2018.