Summer 2017 Piano Camp Registration Form

Choose Your Camp:*
Child's Name*
First Last
Grade and School District (Fall 2017)*
Parent/Guardian Name*
First Last
Phone Number for Calls or Messages About Class*
Name and Number of Emergency Contact if You Cannot Be Reached*
Parent/Guardian Preferred Email Address*
Parent/Guardian Address*
Street Address Address Line 2 City State ZIP Code
How will you be paying?*
- Online
- Sending check in the mail
- Check/cash at BOTTLE WORKS
Please tell me about your child: musical interests, strengths, medical or behavioral concerns, etc.*
If you have an instrument at home, please describe it: acoustic/digital, brand, number of keys, condition, etc.
May I show your (unidentified) child in a photo or video on my website or Facebook page?*
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