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Music Academy of Eastern Carolina
252-353-MAEC
1400 Red Banks Road
Greenville, NC 27858
2011 – 2012 Student Registration Form
STUDENT INFORMATION (Only one applicant per form.)
New Student
Continuing Student
Last Name
First Name
Street
Middle
City
Date of Birth
Home Phone
Ethnicity
Former Student
/ /
NC Zip
Sex
eMail address
School
Grade
(for grant purposes)
(09-10)
Special Needs & Medications
If you are a new student, please indicate any previous musical training.
With whom did you study?
For how long?
Billing Information (If person paying bill is someone other than above.) College students, please list permanent address.
Name (First & Last)
Street
Phone
City
NC Zip
Head of Household’s Name (First & Last)
Employer
Work Phone
Cell
Spouse’s Name (First & Last)
Employer
Work Phone
Cell
Scheduling Preference (If you are a new student, please call the office to discuss available openings before returning this form.)
Private Lessons:
Instrument
Instructor
Day
Time
Length
Classes and/or Ensembles:
I was referred to MAEC by:
I/We grant the Music Academy of Eastern Carolina permission to make still photos, video or sound recordings to
use for marketing and/or communication purposes. I have read the policies of MAEC as written and agree to abide
by them.
Signature
For office use: Date Received
Start Date
Date_____________________
Paid Registration Fee by: Cash Visa MC Check #
# weeks to be billed
Withdrawal Date
Amount Due $______ Registration Fee & Tuition
_____ Ensemble
11-12 Student Registration Form.pdf (PDF, 84.75 KB)
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