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
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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
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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
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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.
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Location and date
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Participant’s signature
In the case underage participant:
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Parent’s signature
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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
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