Fall Group Piano Registration Form

DES MOINES SYMPHONY ACADEMY
GROUP PIANO REGISTRATION FORM-FALL 2008

 

___ MUSIC FOR LITTLE MOZARTS                     $130 (10, 45-minute sessions)

__________ Mon. 4:30pm          __________ Mon. 5:15pm          __________Tues. 5:15pm

__________ Wed. 6:15pm          __________ Fri. 5:15pm            __________ Sat. 11:00am

 

_____ MUSIC FOR MOPPETS                    $185 (10, 45-minute sessions)

__________Tues. 4:30pm          __________Thurs. 6:30pm          __________Fri. 4:30pm         __________ Sat. 11:45pm

 

_____KINDERKEBOARD                    $210 (10, 60-minute sessions)

__________ Wed. 4:30pm          __________ Sat. 9:00am

 

_____MUSIC 1A                    $210 (10, 60-minute sessions)

__________ Wed. 5:30pm          __________ Fri. 6:00pm          __________ Sat. 10:00am

 

REGRISTRATION INFORMATION
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_____ I was enrolled in Winter Semester and my contact information has not changed

Student______________________________________________________________     DOB_________________________

Parent/Guardian______________________________________________________________________________________

Mailing Address_______________________________________________________________________________________

City_______________________________________________     State________________            Zip________________

Daytime Phone____________________________     Email Address___________________________________________

Payment Information

_____ Credit Card                                    Visa______               Master Card______ 
Credit Card Number______________________________________________________________________     Exp. Date____________
Charge Amount________________________________

_____ Check          Check Amount_____

 

For Office Only:
Date Received_______________________
Date Processed______________________
Payment Date_______________________