11 12 Student Registration Form

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