First Name*

Middle Name

Last Name*

Street Address*

Street Address 2

City*

State*
Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code*

Province

Country:
Not Applicable AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIQUA AND BARBUDA ARGENTINA ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN AZORES ISLANDS BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA-HERZEGOVINA BOTSWANA BRAZIL BRITISH VIRGIN ISLANDS BRUNEI BULGARIA BURUNDI CAMBODIA CAMEROON CANADA CANAL ZONE CAPE VERDE ISLANDS CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHANNEL ISLANDS CHILE COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO COOK ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC CZECHOSOLVAKIA DEM PEOPLE'S REP OF KOREA (NORTH) DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ESTONIA ETHIOPIA FALKLAND ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTH ANTARCTIC TERRITORY GABON GAMBIA GERMANY GHANA GIBRALTAR GILBERT ISLANDS AND TUVALU GREECE GREENLAND GRENADA GUADELOUPE GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISLE OF MAN ISRAEL ITALY IVORY COAST JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KUWAIT KYRGYSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARTINIQUE MAURITANIA MAURITIUS MEXICO MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURA NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORTHERN IRELAND NORWAY OMAN PACIFIC ISLANDS PAKISTAN PANAMA PAPUA NEW GUINEA PARAGUAY PEOPLE'S DEMOCRATIC REP OF YEMEN PEOPLES' REPUBLIC OF CHINA PERU PHILIPPINES PITCAIRN ISLANDS POLAND PORTUGAL QATAR REPUBLIC OF GEORGIA REPUBLIC OF KOREA (SOUTH) REUNION ROMANIA RUSSIA RWANDA SAINT LUCIA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA ST, PIERRE AND MIQUELON ST. CHRISTOPHER AND NEVIS ST. HELENA ST. VINCENT AND THE GRENADINES SUDAN SURINAME SVALBARD/JAN MAYAN ISLANDS SWAZILAND SWEDEN SWITZERLAND SYRIA TAHITI TAIWAN, REPUBLIC OF CHINA TAJIKISTAN THAILAND TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS UGANDA UKRAINE UNION OF MYANMAR UNION OF SOVIET SOCIALIST REPUBLICS UNITED ARAB EMIRATES UNITED KINGDOM UNITED REPUBLIC OF TANZANIA UNITED STATES UPPER VOLTA URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM WALES WALLIS AND FUTUNA ISLANDS WESTERN SAHARA WESTERN SAMOA YEMEN ARAB REPUBLIC YUGOSLAVIA ZAIRE ZAMBIA ZIMBABWE

Day Phone*
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Evening Phone
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Mobile Phone
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Email Address*

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Gender*
 Male       Female

Educational Level
8th grade 9th grade 10th grade 11th grade 12th grade Trade School Some College B.A. M.A. Ph.D. M.D. J.D. Other

Age*

Date of Birth*

(mm/dd/yyyy)

Specify any health problems, allergies or disabilities (maximum 1000 characters)

Would you like to receive UCSD Jazz Camp updates via email?*
 Yes       No

How did you first hear about UCSD's Jazz Camp?

What is your instrument?*
Piano Bass Electric Bass Drums Percussion Guitar Sax – soprano Sax – alto Sax – tenor Sax – baritone Flute Trumpet Trombone Other

How many years have you played this instrument?*

Second Instrument?
Piano Bass Electric Bass Drums Percussion Guitar Sax – soprano Sax – alto Sax – tenor Sax – baritone Flute Trumpet Trombone Other

How many years have you played this instrument?

Tell us about your past experience playing jazz (maximum 1000 characters) *

Open Form* 0 1 2 3 4 5

Bebop/Mainstream* 0 1 2 3 4 5

Hard Bop* 0 1 2 3 4 5

Instructor 1

Instructor 2

Would you like to stay on campus?*
 Yes      No

If you know someone who will be attending the UCSD Jazz Camp, you may request them as a roommate. Otherwise one will be assigned to you.

Requested roommate's name

List any restrictions regarding food and diet (maximum 1000 characters)

First Name*

Last Name*

Relationship*

Day Phone*
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Evening Phone
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Mobile Phone
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Email Address*

Confirm Email Address*