Student Enrollment Form

Student Enrollment

Thank you for supporting music education!
Student Information
Student's Name *

First Name Last Name
Grade
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Information
Name *

First Name Last Name
Home Number

Area Code Phone Number
Cell Number *

Area Code Phone Number
E-mail
Loaner Instrument
Emergency Information

(different person than parent info above)
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Student Waiver Agreement *
Please select for promotional use of student work or images, detailed at http://beyondthegrade.org/contact/student-waiver-form/
Location: *
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, 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.
Payments through Paypal
Should be Empty: