Fine Arts Registration Fall and Spring

First Name

Last Name

Gender

Returning Student

Street Address

City

State

Zip Code

Primary Phone

Secondary Phone

Student Date of Birth

Employer or School

Grade/Position

Parent/Guardian Name (if under 18 – otherwise use N/A)

Parent Cell

Parent Email

Relationship to Student

Emergency Contact Name

Emergency Contact Cell

Emergency Contact Email

Emergency Contact Relationship to Student

Music / Art Level

List Previous Experience

I'm applying for the (check all that apply):

Fall Semester Spring Semester Summer Semester 4-Weeks Trial Session

Lesson choice #1

Lesson choice #2

Lesson choice #3

Lesson choice #4

Preferred Instructor

Preferred start time

Select Session Time

30 min per session 45 min per session 60 min per session

Preferred Payment Method

Pay by Check Automatic Bank Draft

Scholarship

Yes, I am interested in scholarship information

Group Class

Yes, I am interested in group classes

For More Information

Please use the contact information below with any questions.

Terri Thomas

Administrative Assistant to Music and Media (239) 790-0304

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