Queen City Registration Form

Student Information

Student Name *

First

Last

Student Date of Birth (MM/DD/YYYY)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Current Grade in School

School Student Attends

Primary Instrument

Secondary Instrument

T-Shirt Size

Parent / Student Communication

Parent / Guardian's Name *

First

Last

Parent / Guardian Email *

Parent / Guardian's Cell Phone *

Best way to contact you

I would like to receive all student related communication.

Student's Email Address

Student's Cell Phone

Will be used for program specific communication with permission.

I give permission for the Manchester Community Music School staff to text my student program specific announcements, learning information and day of changes.

Emergency Contact and Drop-off / Pick-up information

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact Phone 2

Relationship to Student

Student Health Concerns (allergies, conditions, medications)

Who is allowed to pick up your student?

How will your student be getting to and from the Music School each week?

Grant Related Ethnicity Information (optional)

This information is voluntary, however it helps secure much needed funding for the program. All information is completely confidential and reported out in number only. Please indicate all that apply for you or your student:

Photo Release

I grant Manchester Community Music School, its legal representatives and assigns, irrevocable permission to publish in any manner (including but not limited to: print advertisements, periodicals, website, social media) images / video / interviews of my child or myself.

Manchester Community Music School

Queen City Registration Form

Student Information

Parent / Student Communication

Emergency Contact and Drop-off / Pick-up information

Grant Related Ethnicity Information (optional)

Photo Release

Questions?

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Our Mission

Changing lives through the power of learning, sharing and making music.

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