After School Music Program Registration Form
Musication LLC
Student's Name
*
First Name
Last Name
Birth Day
*
-
Month
-
Day
Year
Date
Grade
*
K
1
2
3
4
5
Best Phone Number to Reach
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian 1 Name
*
First Name
Last Name
Relationship
Mother
Father
Grandparents
Legal Guardian
Other
Phone Number ( if different from above)
Please enter a valid phone number.
Format: (000) 000-0000.
Email ( if different from above)
example@example.com
Parent / Guardian 2 Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Student's Primary Instrument
*
Violin
Viola
Cello
Bass
Level of this instrument Education
*
No experience
Beginner ( 0 - 2 years )
Intermediate ( 2 - 5 years )
Advanced ( 5 + years )
Program Interested
*
String Ensemble Program (Tuesday 3:30 - 4:30 pm)
Cello Ensemble Program (Thursday 4:30 -5:30 pm)
Beginner Cello Group Class ( Monday 4:15 -5:00 pm)
Beginner Violin Group Class ( Wednesday 3:30 -4:15pm)
Music Theory Group Class ( Monday 3:30 -4:15 pm)
Photo/Video Image Release I give Musication LLC permission to photograph and record video images and audio while my child participating in Musication program. I understand these images and recordings may be used by Musication LLC., for purposes of marketing and / or promoting the interests of Music Education. I agree that neither I nor the musician ( my child) will receive compensation for Musication LLC’s use of such images or recordings
*
Yes
I do NOT accept the terms and conditions for photo/video image release.
By my online signature, I agree to Musication classroom policy, I release liability, and I agree to set billing for my student to participate in the Musication LLC Music Program
*
Yes I accept the above terms and conditions
Signature
*
Registration Fee
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$30 Registration fee Pay Now
$30.00
$
30.00
$30 Registration Fee Pay Later
Free
$
Free
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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