EmailMe Form - Group Piano Lessons

Child's Name *

First Last

Gender *

Female

Male

Age *

Date of Birth *

MM / DD / YYYY

Tuition:
Group Piano Classes is a four week course.

Cost: $160.00 for all four classes (Includes cost of keyboard, which the student gets to keep.

Due by July 9, 2017.

Classes will be held at First United Methodist Church, 225 E. Duval Street, Jacksonville, FL 32202.

Please choose one class to register for. *

5:30 pm-6:15 pm for Rising Kindergartners - 1st Graders

6:15 pm - 7:00 pm for Rising 2nd -3rd Graders

Ethnicity *

Parents or Guardians *

Child's Home Mailing Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent 1/Guardian 1 Contact information

Name *

First Last

Home Phone *

### - ### - ####

Employer:

Work Phone

### - ### - ####

Cell Phone *

### - ### - ####

Email *

Parent 2/Guardian contact information

Name(2)

First Last

Home Phone (2)

### - ### - ####

Employer:(2)

Work Phone (2)

### - ### - ####

Cell Phone (2)

### - ### - ####

Email(2)

In consideration of my child's participation in the Jacksonville Children's Chorus Group Piano Classes, I hereby authorize the videotaping, photography, and recording of the above referenced registrant, and/or release of his/her name and achievements for educational, promotional, and other purposes deemed appropriate by officers of the Jacksonville Children's Chorus. I also authorize the use of the videotape/photography and other information regarding my child in printed matter or other media for presentations by the Jacksonville Children's Chorus without my further consent. I hereby agree that such media information shall be the sole property of the Jacksonville Children's Chorus. *

I agree

How did you hear about our "Group Piano Class" program? *