!
Student Enrollment Form 2016-2017 _______________________________________________________________________________ Student’s Name: __________________________________________________________________ Last
First
Middle Initial
Billing Address: __________________________________________________________________ House Number & Street
City
State
ZIP
Phone #’s: ______________________________________________________________________ Please indicate father’s home (fh), work (fw), cell (fc) & mother’s home (mh), work (mw), cell (mc).
DOB: ____________ Gender: ____ Grade: ____ School: _______________ Ethnic Origin: ______
For Statistical Purposes Only
Father/Guardian: _________________________________________________________________ Suffix
First Name
Last Name
Occupation
Employer
Mother/Guardian: _________________________________________________________________ Suffix
First Name
Last Name
Occupation
Employer
Email(s): ______________________________________________________________________ Please indicate father’s home (fh) or work (fw), & mother’s home (mh) or work (mw)
_______________________________________________________________________________ Private Lessons in (instrument/voice): _____________________ Ensemble: _______________________ _______________________________________________________________________________ History of Music Lessons Instruments studied: _________________________ Voice Part (circle one): Soprano Alto Tenor Bass # Years of Study: ________________ Previous Teacher(s): _______________________________ History of Lessons: _______________________ Currently studying with another teacher? _______ Anything else we should know about your musical background? Other hobbies/activities? _______________________________________________________________________________ _______________________________________________________________________________ Where did you hear about Community Music School? ____________________________________ _______________________________________________________________________________ I certify that the information provided above is current, accurate and truthful in all respects. I have read, understand, and will abide by the polices of Community Music School as stated in the Student Handbook, website, and contract and accept responsibility for all tuition and fees incurred.
Parent/Guardian Signature: ___________________________________ Date: _______________ _______________________________________________________________________________
OFFICE USE ONLY Date: ___________Assigned to Teacher: ______________________________ Length of lesson __________________ Day _______________ Time __________ Location _________________ Instrument/Ensemble ___________________ Downtown Allentown | West Allentown | Bethlehem | Center Valley | Reading ________________________________________________________________________________________________________________________________________________________________________________________________________________________
Main Office
23 North Sixth Street
Allentown, PA 18101
610-435-7725
fax 610-435-1411
cmslv.org
[email protected]
