Music Box Foundation Spring Registration Form
Classes starting January 10th - May 4th
Is your child a new or returning student for Saturday Sessions?
*
New
Returning
Student Name
*
First Name
Last Name
Student birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child need a replacement t-shirt?
Yes
No
Student T-Shirt size
*
Small
Medium
Large
X-Large
2X-Large
3X-Large
Please select a program: Dance 11:30 AM - 1:00 PM, Sessions w/ instrument 1:30 PM - 3 PM *Times may change due to class size*
Dance
Guitar
Brass
Clarinet
Piano
Percussion
We provide snacks at the end of the day. Does your child have any allergies or food restrictions? If so, please list them below or type N/A.
Are you registering more than one student?
*
Yes
No
Additional Students
Is your child a new or returning student for Saturday Sessions?
*
New
Returning
Student Name
*
First Name
Last Name
Student birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child need a replacement t-shirt?
Yes
No
Student T-Shirt size
*
Small
Medium
Large
X-Large
2X-Large
3X-Large
Student already has a shirt
Please select a program: Dance 11:30 AM - 1:00 PM, Sessions w/ instrument 1:30 PM - 3 PM *Times may change due to class size*
Dance
Guitar
Brass
Clarinet
Piano
Percussion
We provide snacks at the end of the day. Does your child have any allergies? If so, please list them below or type N/A.
Are you registering any additional students?
*
Yes
No
Additional Students pt.2
Is your child a new or returning student for Saturday Sessions?
*
New
Returning
Student Name
*
First Name
Last Name
Student birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child need a replacement t-shirt?
Yes
No
Student T-Shirt size
*
Small
Medium
Large
X-Large
2X-Large
3X-Large
Student already has a shirt
Please select a program: Dance 11:30 AM - 1:00 PM, Sessions w/ instrument 1:30 PM - 3 PM *Times may change due to class size*
Dance
Guitar
Brass
Clarinet
Piano
Percussion
We provide snacks at the end of the day. Does your child have any allergies? If so, please list them below or type N/A.
Parent/Guardian Information
Parent Guardian name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Terms & Agreements
I hereby give permission for my child to participate in all activities sponsored by Music Box Foundation, including performances and field trips. I fully assume responsibility for injuries he/she or I may receive or articles lost while participating in these activities. In addition while traveling to/from said activities and field trips, and hereby release Music Box Foundation and its employees from liability for any injury I or my child may sustain. *
*
I agree
I hereby give permission to Music Box Foundation for use of any photos in which my child(ren) may appear. The usage is inclusive of, but not limited to, the publication or inclusion in brochures, posters, catalogs, handbooks, banners, websites, and broadcast or print advertisements. I agree to waive any claim to compensation for use of said photos.
*
I agree
I have received, read, and understand the "Terms & Agreements" and agree to abide by the policies stated therein. I have read and agree to the information contained in the above Parental Agreement and have filled out the emergency contact information for my child(ren).
*
I agree
Payment Information
Would you like to submit a payment now or start a payment plan at the office?
Pay now
Pay later *Check all that apply, leave quantity "0" and credit card info should be blank.
Payment is due at the student's first class. *Payment plans are also available with Kijuana Carter.*
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Dance Class
$85.00
$
85.00
Quantity
0
1
2
3
New Student Music Class
$125.00
$
125.00
Quantity
0
1
2
3
Returning Student Music Class
$85.00
$
85.00
Quantity
0
1
2
3
Child T-Shirt
New students MUST purchase a t-shirt.
$10.00
$
10.00
Quantity
0
1
2
3
4
5
6
7
8
9
10
Adult T-Shirt
$20.00
$
20.00
Quantity
0
1
2
3
4
5
6
7
8
9
10
Credit Card
Submit
Should be Empty: