Student Name (required)
School Attended Birch HillAmherst StBicentennialDr. CrispMain DunstableNew SearlesMt. PleasantHome SchoolOther
Grade
Instrument Choice ViolinViolaCello
Would you like to have a high school student tutor practice with your 3rd to 5th grade student one day per week Yes for a tutorNo for a tutor
Primary Contact Name
Home Address
Home Phone
Cell Phone
Email Address
Lessons or performances might be photographed or videotaped with the intent to publish on our website, facebook page or utilize in grant applications. Permission to use photograph YesPermission to use photograph No
Permission to use child's name with photography. Permission to use name YesPermission to use name No
Allergies YesNo
I HEREBY AUTHORIZE ANY LICENSED PHYSICIAN, HOSPITAL, CLINIC OR OTHER MEDICAL FACILITY TO HOSPITALIZE AND SECURE PROPER TREATMENT FOR MY CHILD NAMED ABOVE
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