Student Name (required)
School Attended Birch HillAmherst StBicentennialDr. CrispMain DunstableNew SearlesMt. Pleasant
Grade
Instrument Choice ViolinViolaCello
Primary Contact Name
Home Address (Street, City, State, Zip)
Home Phone
Cell Phone
Email Address
Lessons or performances might be photographed or videotaped with the intent to publish on our website, facebook page or utilize in grant applications. Permission to use photograph YesPermission to use photograph No
Permission to use child's name with photography. Permission to use name YesPermission to use name No
Allergies (Please list all allergies, select 'no' if student has no allergies) YesNo
I HEREBY AUTHORIZE ANY LICENSED PHYSICIAN, HOSPITAL, CLINIC OR OTHER MEDICAL FACILITY TO HOSPITALIZE AND SECURE PROPER TREATMENT FOR MY CHILD NAMED ABOVE
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