Registration Form

Name: *
Age: *
Address: *
Gender: *
Phone: *
-
Cell No.:

PARENT/GUARDIAN INFORMATION

Mother's Name: *
Mother's Phone Number:
Father's Name: *
Father's Phone number:
Parent's Address: *
Mother's place of work:
Father's place of work:
Does your child have any medical or handicapping conditions including allergies?
Please indicate your child’s previous music/art experience (school/camp/classes) and interests.
Is there any other information about your child you would like us to know? (i.e. special  interest/talents, fears, school/social issues, etc.)

EMERGENCY INFORMATION

Emergency contact person:
Contact No.:
Relationship to Student:

MUSICAL STUDY

Instrument you wish to study:
Type of lesson(Musical Study):
If private lessons select duration:
If you are enrolling in group lessons, list name and time:
Number of years of previous instruction:
Name of previous teachers:

VISUAL ART

Type of lesson(Visual Arts):
If private lessons select duration::
If you are enrolling in group lessons, list name and time::
Number of years of previous instruction::
Name of previous teachers::

BILLING INFORMATION

Name::
Address::
Phone::
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Piano and Violin Fees for the Fall Semester:  *