EmailMe Form - Greater Cumberland Baptist Church

Parent/Guardian Name *

Family Address *

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

Email *

Receipt should be received within 24-48 hrs.

Confirm email address

Child Information *

Emergency Contact Information *

Please Check if same as above

Address

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

Phone

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

Relationship To Child *

Which class will the child be taking: *

Music for Babies (0-2)

Tiny Tots (2-4) *foam-a-lin only

Violin Clinic (2-adult) *violin only

Tiny Tots Information

Need Foam-a-lin (additional $17.00)

Have Foam-a-lin

Violin Clinic Information

Number of Years Played Violin
Current/Recent Teacher
Piece currently working on *please bring