EmailMe Form - Carolina Music Outreach Student Application

Student Name: *

Guardian Name: *

Address: *

Email: *

Phone Number: *

Age: *

Sex:

Male

Female

Instrument Choice #1:

Instrument Choice #2:

Yes, I have reliable transportation to get my child to his/her music lesson every week.

Yes

No

Please mark the days for the 5 PM slot you are available for lessons:

Please mark the days for the 5:40 PM slot you are available for lessons:

Please mark the days for the 6:20 PM slot you are available for lessons: