Fall 2022 Continuing Student Registration Form

FALL 2022 Continuing Student Registration Form

Please fill out this form completely -this includes making a 2nd choice - even if it is the same class as your 1st choice. We do consider your 2nd choice a viable option. Completing the form also includes that you read the POLICIES AND WAIVERS and scroll down, then, check the box that you have read them. It also includes that you read the AUTHORIZATION AND RELEASE FROM LIABILITY REGARDING IN-PERSON MUSIC INSTRUCTION and scroll down, the check the box that you have read. You must also make your total payment, or the registration form will not be processed. You do not need a PayPal account to pay - you can use any credit card. You will receive your registration confirmation after August 27, 2022 If you are enrolling more than one family member, be sure to put FAMDIS in the Discount Code Box.
Person Filling out this form *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email Address *
Phone Number *

Area Code Phone Number
Additional Caregiver Name *

First Name Last Name
Additional Caregiver Email Address *
example@example.com
Student 1 Name *

First Name Last Name
Student 1 Birth Date *

Month Day Year
Has this student been in a BMEC class before? *

Yes No
Student 1 Class Selection - Choice 1 *
Student 1 Class Selection - Choice 2 *
Are you enrolling another student? *

Yes No
Student 2 Name *

First Name Last Name
Student 2 Birth Date *

Month Day Year
Has this student been in a BMEC class before? *

Yes No
Student 2 Class Selection - Choice 1 *
Student 2 Class Selection - Choice 2 *

My Products *

Musical Beginnings $ 100.00

Quantity

Music for Little People - Age 2 $ 120.00

Quantity

Music for Little People Age 3 $ 120.00

Quantity

4's/5's Encounters - Ages 4/5 $ 150.00

Quantity

New Piano Experiences - Ages 6/7 $ 250.00

Quantity

Enter coupon

Total $ 0.00

Additional Comments

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.

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