Eastman School of Music Class of 2013 Family Information Form
* Required
First Name:
*
Nickname (if applicable):
Middle Name:
Last Name:
*
Sex:
*
Male
Female
Major:
*
Applied Music (Performance)
Music Education
Jazz Studies and Contemporary Media
Theory
Composition
Instrument
*
Please select one
Basson
Cello
Clarinet
Double Bass
Drumset
Euphonium
Flute
Guitar
Harp
Horn
Oboe
Organ
Percussion
Piano
Saxophone
Trombone
Trumpet
Tuba
Viola
Violin
Voice
Home Address:
*
Street, City, Sate, Zip, Country
Home Phone:
*
Date of Birth:
*
Month
Please select one
January
February
March
April
May
June
July
August
September
October
November
December
Date of Birth:
*
Day
Please select one
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Date of Birth:
*
Year
Please select one
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Anticipated Graduation Date from Eastman
*
May 2014
May 2013
May 2012
May 2011
Seasonal Address (if applicable):
Street, City, State, Zip, Country
Seasonal Address Valid Dates:
FATHER/GUARDIAN Name:
Relationship to Student:
Home Address (if same as yours, write "Same"):
Street, City, State, Zip, Country
Home Email:
Profession/Occupation:
Position/Title:
Name of Firm/Company:
Business Address:
Street, City, State, Zip, Country
Business Phone:
Business Email:
Retired?
Yes
No
Corporate/Foundation/Civic/Board Memberships:
College Attended, Degree & Year:
Graduate School, Degree & Year:
MOTHER/GUARDIAN Name:
Relationship to Student:
Home Address (if same as yours, write "Same"):
Street, City, State, Zip, Country
Home Phone:
Home Email:
Profession/Occupation:
Position/Title:
Name of Firm/Company:
Business Address:
Street, City, State, Zip, Country
Business Phone:
Business Email:
Retired?
Yes
No
Corporate/Foundation/Civic/Board Memberships:
College Attended, Degree & Year:
Graduate School, Degree & Year
Check if Appropriate:
Parents divorced
Parents separated
Father deceased
Mother deceased
Father remarried?
If yes, please provide step-parent's name
Mother remarried?
If yes, please provide step-parent's name
Please list all Eastman and other University of Rochester relatives (including immediate family):
For each relative, please provide his/her name, class year, and relationship to you.
Please list all siblings:
Please provide each sibling's name, date of birth, last school attended and graduation year.