Participant's Name *

First Name

Last Name

Preferred Phone *

(###)

###

####

Address *

Student or primary parent's home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age Group *

Toddler 1-3

Pre K and Early Elementary 3-6

Elementary 6-8

Pre Teen 8-12

Teen 13-17

18 still in high school

Agreement to follow rules *

Do you agree to follow the class rules, which include having respect for the facility in use as well as for each other?

yes

no

Materials Cost *

There is no cost for these music groups, however if your student intentionally breaks one of our instruments, or any of the facility materials you could be charged for this. Do you agree to pay for materials damaged due to misuse or disrespect of equipment?

yes

no

Date

MM

DD

YYYY