Rochester Registration Form
Fields with an asterisk (*) are required.
Student Name
*
Parent/Guardian Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Street Address
*
City
*
ZIP Code
*
Phone Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Which type(s) of instruction are you most interested in? (Check all that apply.)
*
Private Lessons
Group Lessons
Musical Enrichment
Which instrument(s) are you most interested in?
*
Do you have an instrument for practice at home?
*
Yes
No
Please discuss any special needs (learning, behavioral, environmental, or medical) that may be relevant to the student's instruction. If there are none, please enter "N/A."
*
0/150
Preferred Location
*
East Rochester Studio
Remote/Online Instruction
Other
Which days and times are best for scheduling?
*
Weekday Mornings
Weekday Afternoons
Weekday Evenings
Saturday Mornings
Saturday Afternoons
How did you hear about MEC? If you were referred by a friend, please include their name.
Do you have any coupons, vouchers, or other discounts to apply?
I give Music Education Centers (MEC) permission to use photographic and/or video documentation of myself or my child for promotional and educational purposes including internet publishing, staff training, and as an educational tool for other professionals.
*
Yes
No
I have read and agree to the policies and fees outlined on the MEC website.
*
Yes
CAPTCHA: For security purposes, please enter the text as it's shown below.
*
Submit
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