TODAY'S DATE:_______________________

How did you hear about our music classes/lessons?

Web page_____ flyer______ mailing______friend______0ther________(please specify)

STUDENT INFORMATION

Child's Name____________________________________

Child's Age (as of first day of class)________ Date of Birth:__________

Parents' Name(s)___________________________________________

Address:_________________________________________________

City, State, Zip Code________________________________________

Phone:____________________ Email:_________________________

Cell Phone:___________________________________________

CLASS INFORMATION

Class Name:  SUMMER: Blast Off with Piano____      EZ Keys (5 yrs)____      Menehune (6 yrs)____     Level 1 (7-10 yrs)_____

Class Semester Fall_____ Spring_______ Summer______

First Choice Day___________ Time______________     or  WEEK LONG CLASS: WEEK OF__________________

Second Choice: Day___________ Time______________   or  WEEK LONG CLASS: WEEK OF__________________

* If you would like to be placed in a class with a friend or relative, write their name here. We will do our best to honor requests._______________________________

Tution Total ___________
Less 10% for  sibling discount ___________
Materials/Registration Fee (non-refundable) ___________

Total Due for Class/Semester ___________

Please make checks payable to Wendy Moyer
Thank you for your registration. We will confirm your registration via phone or email.

Moyer Music Studio 2890 W Owasso Blvd Roseville, MN 55113
651-293-6396 www.wendyspiano.com wendy@pmoyer.org

MEDIA RELEASE
I give permissions for my child's and any caregiver's/observer's images to be used in any Moyer Music Studio publications, promotional materials, videos, slide shows, and the Moyer Music Studio website.

Parent Signature___________________________________________Date____________