Southampton Summer Music - July 23 - 27, 2018
Home Coming Events
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Fields marked with a * must be completed.

 

First Name* :

Last Name* :

Name of Parent/Legal Guardian (If Under 18):

Registrant or Parent/Legal Guardian Phone No (If Under 18) :
Phone number if entered must include the area code in the following format : 123-456-7890

Email:*

Please re-enter your email address:*

Gender*:

Male Female

Age (as of December 31, 2018)* :

Address*

Address - Line 2

City / Town*

Postal Code/ Zip Code*

REGISTRATION FEES

I will be paying my registration fees by* :

Credit Card/Paypal Cheque

Please Note
: PayPal will accept the following credit cards: Visa, MasterCard, American Express, Discover, JCB, Diner's Club and EnRoute

You do NOT require a PayPal account to pay with your credit card.

Name on Credit Card/PayPal or Cheque that will be used to pay registration fees* :


Emergency Local Contact - Name*

Emergency Local Contact - Address*

Emergency Local Contact - Phone Number*
Emergency phone number must be entered with area code in the following format : 123-456-7890

PHOTO RELEASE: Permission to use registrant photos in printed material * :

Yes No

PHOTO RELEASE: Permission to use registrant photos on Summer Music website, social media * :

Yes No

Grade completed in June 2018( if under 18):

For Instrumental Programs - Instrument:

Years Played:

Years of private instruction:

Program: *

 

Tots & Tunes Mornings (4-5 yrs old) - $135.00

Musical Beginnings (6-8 yrs old) - $250.00

Instrumental Beginnings (8-11 yrs old) - $250.00

Choral (9-11 yrs) - $250.00

Choral (12 yrs & up) - $250.00

Instrumental - $250.00

Jazz (Instrumental) - $300.00

Jazz (Vocal) - $300.00

Camper T-Shirt:*

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Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult XX Large

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