2009-2010 Registration

Student Name_____________________________________________________________________________

Age__________________________________ Birth date  __________________________________________

School__________________________________________________Grade____________________________

Address___________________________________________________________________________________

Home Phone_______________________________________________________________________________

Student Email (optional)_____________________________________________________________________

Student Cell (optional)_______________________________________________________________________

Parent_______________________________________________Cell__________________________________

Parent_______________________________________________Cell__________________________________

Phone numbers & or emails for Lesson Exchange Roster____________________________________________

_________________________________________________________________________________________

#1 choice of lesson time______________________________________________________________________

#2 choice of lesson time______________________________________________________________________

#3 choice of lesson time______________________________________________________________________

Please check if applicable

My lesson time selection is flexible____________________

I do not wish to be included on the Lesson Exchange Roster___________

I have included with this registration my registration fee of either $20 for piano or $40 for voice and my September lesson fee.___________________________________________________________________

I understand and agree to abide by The Fielder Studio of Music Policy 2008-2009____________________

Student Signature __________________________________________________Date_________________

Parent Signature____________________________________________________Date________________