EmailMe Form - 21-22 PBS School Of Music Registration Form

Participants Name *

First Last

Gender

Male

Female

Birthday *

(mm/dd/yy)

Name of School Attending

Current Grade Level

Classroom Teacher

Parent/Guardian Name *

First Last

Address *

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

Cell Phone *

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

Email *

I have read and agree with tuition payment policy: *

Yes

No

Area of Study *

Instructor Requested

Level of Instruction

Beginner

Intermediate

Advanced

Second Area of Study (If applicable)

Instructor Requested 2 (If applicable)

Level of Instruction 2 (If applicable)

Beginner

Intermediate

Advanced

Emergency Contact Name *

First Last

Emergency Contact Phone *

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

Media Permission

Yes

No

I hereby grant Parkview Baptist School Of Music employees the right to photograph my child and use the photo and/or other digital reproduction of him/her for publication processes, whether electronic, print, or digital publishing via the internet.

Special Requests (lesson day/time/preferred pull-out)

Registration Payment

When you hit 'Submit,' you will be directed to the online payment page. You do NOT have to create a Paypal Account. Simply hit 'Pay with Credit or Debit Card.'