Application/Registration
Child's Name
First Name
Last Name
Childs Date of Birth
-
Month
-
Day
Year
Date
What Musical Instrument or Art form are you interested in? You can pick more than one.
*
Djembe Drum
Cartooning
Trumpet
Piano
Painting
Drawing
Sculpting
Free African Dance Class
Parents Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dad's Name / 2nd Parent's Name:
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mom's Phone Number
-
Area Code
Phone Number
Mom's Email:
example@example.com
Dad's Phone Number
-
Area Code
Phone Number
Dad's Email:
example@example.com
EMERGENCY CONTACT INFO.
Emergency Contact:
First Name
Last Name
Emergency Contact Phone #:
-
Area Code
Phone Number
Please use this space below to submit additional names, phone #'s of responsible family & friends for Emergency contact!
Please # 1,2,3,4, etc. for the additional family members for emergency contact.
PAYMENT PORTAL
Tuition Payments
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Saturday Music & Arts Registration
$
40.00
Monthly Tuition Payment
$
175.00
Quantity
1
2
3
4
Item subtotal:
$
0.00
Total
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Submit
Should be Empty: