Registration Form - Stowarzyszenie Menedżerów i Organizatorów
Transkrypt
Registration Form - Stowarzyszenie Menedżerów i Organizatorów
Registration Form For the educational project called: 1st INTERNATIONAL MASTER COURSES – MASTER GUITAR COURSE 29 June – 5 July 2012, Dietla Palace in SOSNOWIEC 1. Name and Surname: 3. Sex: Female 2. Identification Number: 4. Age: Male 5. Telephone number: 6. Date of birth: 7. Email Address: 8. Place of birth: 9. Home Address: -------------------------------------- 9.1. Country: 9.2. Street: 9.3. Flat/House number: 9.4. Zip Code: 9.5. City: 10. Correspondence Address: ---------------------(if different from Home Address) 10.1. Country: 10.2. Street: 10.3. Flat/House number: 10.4. Zip Code: 10.5. City: 11. Underage participant: YES NO Legal guardian data for underage participant, for the project:-------------------------------11.1. Name and Surname: 11.2. Country: 11.3. Street: 11.4. Flat/House Number: 11.5. Zip Code: 11.6. City: 11.7. Email Address: 11.8. Telephone number: 12. Information about music education (concerns those who have finished their education): Stowarzyszenie Menedżerów i Organizatorów Kultury S M O K, ul. Mikołajska 2, 31 – 027 Kraków www.kulturalnysmok.pl ; e-mail: [email protected] ; REGON 121241247 ; NIP 6762423133 Organ rejestrowy: Sąd Rejonowy dla Krakowa – Śródmieścia, XI Wydział Gospodarczy, nr KRS 0000299878 1 13. School/ University Name/ Work Place: 13.1. School/ University/ Work Place Address: -------- 13.2. Country: -13.4. Street: 13.4. Flat/House Number: 13.5. Zip Code: 13.6. City: 14. Year in Music School: Year of study: Not Applicable: 14.1. Teacher’s name (in case of school and university students): 15. Detail of the guitar team (regarding only guitar team): 15.1. Name: 15.2. Date of the start: 15.3. Constitution of the team: 1. 2. 3. 4. 5. 16. Teacher’s native language: a) Polish b) English c) German 17. Type of participation in the project (indicate your choice by ‘X’): 17.3. FOREIGN PARTICIPANTS: ACTIVE– FULL TIME - (5 lessons, participation in concerts, one lecture and practical workshops, full board, accommodation in the Palace): 400 € PASSIVE – FULL TIME - (5 lessons, participation in concerts, one lecture and practical workshops, full board, accommodation in the Palace): 250 € Stowarzyszenie Menedżerów i Organizatorów Kultury S M O K, ul. Mikołajska 2, 31 – 027 Kraków www.kulturalnysmok.pl ; e-mail: [email protected] ; REGON 121241247 ; NIP 6762423133 Organ rejestrowy: Sąd Rejonowy dla Krakowa – Śródmieścia, XI Wydział Gospodarczy, nr KRS 0000299878 2 18.Course program(titles of works, composers’ names): 19. Repertoire proposals for concert organized in the project: “MUSICAL PALACE IMPRESSIONS” – indicate chosen work (titles of works, composers’ names): 1. 2. 3. 4. 5. 20. Source of information about the project: project internet webiste internet information from school/university/work place poster (where?) word of mouth (who?) others (what?) 21. I know and agree to the terms and conditions of participation included in the project regulations and I declare my willingness to participate in the educational project called: “1st INTERNATIONAL MASTER COURSES - MASTER GUITAR COURSE” 22. Hereby, I declare I am insured against dangerous incidents and I commit to comply with the rules in the st place of accommodation as well as during all classes organized in the educational project called: „1 INTERNATIONAL MASTER COURSES – MASTER GUITAR COURSE”23. I hereby authorize you to process my personal data for the needs of the educational project called„1st INTERNATIONA MASTER COURSES – MASTER GUITAR COURSE”, in accordance with the Personal Protection Act 29.08.1997 (number 133 position 883) - Stowarzyszenie Menedżerów i Organizatorów Kultury S M O K, ul. Mikołajska 2, 31 – 027 Kraków www.kulturalnysmok.pl ; e-mail: [email protected] ; REGON 121241247 ; NIP 6762423133 Organ rejestrowy: Sąd Rejonowy dla Krakowa – Śródmieścia, XI Wydział Gospodarczy, nr KRS 0000299878 3 DECLARATION I declare that information submitted by me in the above Registration Form is real. In case of submitting unreal information I am aware of legal responsibility and I am ready to undertake legal responsibility for the damage caused by this. > < > Location and date < Participant’s signature In the case underage participant: > < Parent’s signature > < Legal Guardian’s signature Registration Form sent to 4.06.2012 r. on adress: [email protected] Stowarzyszenie Menedżerów i Organizatorów Kultury S M O K, ul. Mikołajska 2, 31 – 027 Kraków www.kulturalnysmok.pl ; e-mail: [email protected] ; REGON 121241247 ; NIP 6762423133 Organ rejestrowy: Sąd Rejonowy dla Krakowa – Śródmieścia, XI Wydział Gospodarczy, nr KRS 0000299878 4