Student Evaluations Registration Form

Today's Date * +

Teacher Name *

Is teacher an MTNA member? *

Yes

No (+$30 surcharge per student)

MTNA Number *

Teacher E-Mail Address *

MTNA Member: How many students in each level? 🛈

	Level Prep ($55)
	Level 1 ($55)
	Level 2 ($55)
	Level 3 ($55)
	Level 4 ($55)
	Level 5 ($70)
	Level 6 ($70)
	Level 7 ($70)
	Level 8 ($70)
	Level 9 ($70)
	Level 10 ($70)
	Level 11 ($85)
	Level 12 ($85)

Non-MTNA Member: How many students in each level? 🛈

	Level Prep ($85)
	Level 1 ($85)
	Level 2 ($85)
	Level 3 ($85)
	Level 4 ($85)
	Level 5 ($100)
	Level 6 ($100)
	Level 7 ($100)
	Level 8 ($100)
	Level 9 ($100)
	Level 10 ($100)
	Level 11 ($115)
	Level 12 ($115)

Non-Work Fee (if you are unable to volunteer on the day of the event)

Total Fees:

$0.00

There are no refunds once submitted.

Please read the Teacher Work Requirements below.

Half day if entering 3 or fewer students.
Full day if entering 4-10 students.
Additional full day if entering 11+ students: Teacher will work a full day and provide an additional worker OR work extra hours pre- or post-event, as directed by the Chair.

The penalty for not meeting the work requirements is: $200 for half-day and $400 for full-day. Test results will be withheld until the penalty is paid. *

Yes, I agree to the Teacher Work Requirements.

Media Waiver: By checking YES, you acknowledge that you have read and agree to these Terms and Conditions. By checking YES, you also acknowledge that you are 1) age 18 or older or 2) the parent or legal guardian of the applicant under age 18. I hereby grant my consent to the California Association of Professional Music Teachers, Santa Clara Valley Chapter (CAPMT SCV) to photograph, electronically record, transfer, or film the applicant for distribution in all media at any time, all public performances and appearances in or associated with CAPMT SCV events without any compensation or remuneration. I also grant to CAPMT SCV the right to use any such recorded performances, interviews, quotations or photographs of the applicant; and the right to use the applicant's name, voice, image, and likeness in connection with a CAPMT SCV event, including but not limited to: publication in books, magazines, pamphlets, advertising, and newspapers; and on television, radio, internet, and social media channels, without any compensation or remuneration.

Yes