Quad City Symphony Youth Ensembles

Placement Confirmation Form

Member Name(Required)

First Last

Birth Date(Required)

MM slash DD slash YYYY

Member Instrument(Required)

Are you interested in playing piccolo should the repertoire require it?(Required)

QCSYE repertoire often demands the use of auxiliary instruments. While many school districts offer these for students who play them in the QCSYE, we will assist with securing an instrument if a student is interested in learning.

Are you interested in playing English Horn should the repertoire require it?(Required)

Are you interested in playing E-flat and bass clarinet should the repertoire require it?(Required)

Ensemble for 2025-2026 Season(Required)

Please confirm the ensemble listed on your Welcome Letter.

Grade for 2025-2026 Season(Required)

T-Shirt Size(Required)

Student Email (if applicable)

The email address where your student will receive weekly emails about rehearsals, concerts, etc. Please note that students' school emails often cannot accept emails from outside organizations.

School Name(Required)

Ethnicity(Required)

(Choose all that apply.)

Caucasian

Black or African American

Hispanic, Latino, or of Spanish Origin

Native, Hawaiian, or Pacific Islander

Asian

Other

Parent/Guardian Contact Information

Primary Parent/Guardian 1(Required)

This is the primary email address used for all communication and billing.

First Last

Primary Parent/Guardian 1 Phone(Required)

Primary Parent/Guardian 1 Email(Required)

Primary Parent/Guardian 2

First Last

Primary Parent/Guardian 2 Phone

Primary Parent/Guardian 2 Email

Health Information

This information is confidential and will only be used in the case of an emergency.

Allergies (include severity of reaction & specify type):

Significant medical information/conditions:

Medications currently taken on a daily basis:

I give permission for QCSYE staff members to give my child over-the-counter headache/pain medication (i.e. Advil or Tylenol) if necessary.(Required)

Medical Treatment Authorization(Required)

It is possible that a situation might arise which requires that your child receive immediate medical care at the nearest medical facility. Please select below if your child may undergo routine and emergency medical treatment. Every effort will be made to contact you and/or your child's emergency contacts in an emergency situation.

QCSYE Handbook & Policies

https://qcso.org/education/youth-ensembles/ps-handbook/664

https://qcso.org/education/youth-ensembles/concert-orchestra-handbook/664

https://qcso.org/education/youth-ensembles/ypo-handbook/664

https://qcso.org/education/youth-ensembles/yso-handbook/664

Handbook Agreement(Required)

I understand that the Handbook provides specific information on all Quad City Symphony Youth Ensembles (QCSYE) programs that I will be involved in this year. I acknowledge that I have read the Handbook (hard copies available upon request) and I agree to conform to the rules and regulations of QCSYE.

Media Agreement(Required)

I hereby agree to the audio, video, and photographic recording of any of my performances, demonstrations and official QCSYE activities during my membership by all persons and entities authorized by QCSYE. This/these performance(s) may be selected for unlimited releases for audio, video, print or digital media broadcast, and I agree to waive any compensation and/or benefits. I also agree that my name, likeness, and biography may be used for the purposes of any QCSYE promotion.

Age Agreement(Required)

I hereby agree that any student who is 9 years and younger must be accompanied by an adult or guardian to each rehearsal.

QCSYE Release Waiver(Required)

I, and my parent/guardian, in consideration of my participation in QCSYE, agree to release, indemnify, and hold harmless QCSYE a program of the Quad City Symphony Orchestra Association (QCSOA) and its board trustees, volunteers, officers, employees and agents from any claim or expense arising from my failure to comply with the policies, rules or regulations of QCSYE or by persons or entities other than QCSYE unless caused by the gross negligence of QCSYE, its board trustees, volunteers, officers, employees or agents. We further take responsibility for all instruments, equipment, and personal property in my possession during my participation at QCSYE, and agree to release, indemnify, and hold harmless QCSYE a program of the QCSOA and its board trustees, volunteers, officers, employees and agents from all claims and expenses arising from any damage or loss of personal property, unless caused by the gross negligence of QCSYE, its board members, volunteers, officers, employees, or agents.

School Music Program Enrollment Requirement(Required)

The QCSYE program provides advanced ensemble experiences designed to complement and support core music education opportunities provided by school music programs and private lesson instruction. QCSYE members are required to participate in band, orchestra, mariachi, or choir year-round at the schools where they are enrolled (if applicable, homeschooling students do not need to join a school ensemble program unless desired). School music enrollment will be confirmed for each QCSYE member in late August. Members not able to participate in music at school for reasons beyond their control will be required to submit a written waiver—signed by the music teachers at the school, academic counselor, or school principal/superintendent—in order to participate in the QCSYE program. Tuition is non-refundable in the case that enrollment cannot be confirmed. The QCSYE reserves the right to waive the policy in exceptional circumstances, determined on a case-by-case basis, taking into consideration the needs of the student, school music program, and QCSYE. Such considerations will be reviewed by a committee consisting of a public music educator, Director of Education and Community Engagement, QCSYE Music Director, and QCSO Education Committee member.

Yes, I understand the school music program enrollment requirement policy.

Tuition + Financial Aid Application

Tuition Preference(Required)