Registration

Your Name (required)

Your Email (required)

Student Name (if different)

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

Which Session Are You Registering For:
WinterSpring

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

Preferred Phone

Alternate Phone

Street

City

State
---ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY

Zip

Preferred means of contact
PhoneEmail

How did you hear about 317 Main?

Instrument

Experience

Preferred Instructor

Preferred Day(s)

Preferred Time(s)

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 Group/Ensemble, name of Group

If Little Roots FAMILY class, list names & birthdates of all participants

I give permission to use photos of me/my child for promotional purposesI 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, HenryFest.I would like to make a tax-deductible donation with my tuition payment to support programming at 317 Main in the amount of...
---$10$25$50$100

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