Freestyle Camp M&M

Freestyle Camp M&M (Music & Math)
Student Information
Student's Name

First NameLast Name
Are you currently a Freestyle Percussion Student?

YesNo
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Race

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed an inhaler? If yes, please explain any instructions.
Do you require a scholarship interview?*

YesNo
Household Income*
Number of people in your household*
What's the best number to call to schedule a scholarship interview?*
Please enter a valid phone number.
Guarantee your spot! Registration is first come first serve. A $50 deposit must be paid to be considered registered. In-person payment can be made at The Freestyle Percussion Foundation 2010 Old Springville Rd Suite 124 Birmingham, AL 35215. Please call ahead 205-306-6868.
Payment Preference*

OnlineIn Person
Confirmation BY SUBMITTING APPLICATION, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
My Products
prevnext( X )
Registration (non-refundable)
$50.00

Camp Fee
$325.00

Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Freestyle Camp M&M (Music & Math)