Registration

Summer Session Registration Form

Your Name (required)

Your Email (required)

Student is:
Current StudentNew StudentFormer Student
*current student is anyone who has been a student/camper in the last 12 months

Student Name (if different)

Student Birthdate ---JanFebMarAprMayJunJulAugSepOctNovDec---12345678910111213141516171819202122232425262728293031---201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900

Preferred Phone

Alternate Phone

Street

City

State
---ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY

Zip

Preferred means of contact
PhoneEmail

How did you hear about 317 Main?

Little Roots Baby($140)Little Roots Family($140)Discovery Fiddle (July Session: $80)Discovery Ukulele (July Session: $80)Discovery Piano (July Session: $80)Discovery Fiddle (August Session: $80)Discovery Ukulele (August Session: $80)Discovery Piano (August Session: $80)Discovery Fiddle (BOTH Sessions $150)Discovery Ukulele (BOTH Sessions $150)Discovery Piano (BOTH Sessions $150)Just Jam! Ukulele (July Session: $80)Just Jam! Guitar (July Session: $80)Just Jam! Piano (July Session: $80)Just Jam! Ukulele (August Session: $80)Just Jam! Guitar (August Session: $80)Just Jam! Piano (August Session: $80)Just Jam! Ukulele (BOTH Sessions $150)Just Jam! Guitar (BOTH Sessions $150)Just Jam! Piano (BOTH Sessions $150)Private Lessons, 30 minutes (8 weeks: $272)Private Lessons, 45 minutes (8 weeks: $360)Private Lessons 30 minutes (4 weeks: $136)Private Lessons, 45 minutes (4 weeks: $180)All other groups (*Please list below)

If selected "all other groups", name of Group

Instrument

Experience

Preferred Instructor for Private Lessons

Preferred Day(s) for Private Lessons

Preferred Time(s) for Private Lessons

Lesson Type
---Private 45 min.Private 30 min.Semi-private 45 min.Group/EnsembleLittle RootsDeep Roots
"Semi-private" is two same-level students brought by you

If Little Roots FAMILY or BABY class, list names & ages of all participants

I DO NOT give permission to use photos of me/my child for promotional purposesI would like to be contacted about volunteering to help at 317 Main events including concerts, recitals, and showcases.I would like to make a tax-deductible donation to 317 Main Community Music Center. Yes! I will make a donation with my tuition payment in the amount of...
---$10$25$50$100

I have read and agree to 317 Main's payment procedures and cancellation policy

I have read and agree to 317 Main's Student Safety Guidelines based on State CDC Guidelines