FEBRUARY 2017 WORKSHOP REGISTRATION

    Student Name:

    Age:

    Instrument(s):

    Ensemble Details (if applicable):

    Most Recent Piece Studied:

    Private Teacher's Name:

    Parent Name(s):

    Address:

    Home Phone:

    Cell Phone:

    E-mail:

    Emergency Contact Name:

    Emergency Contact Phone Number:

    Tuition for the February 2017 Workshop is $200.00 and will include the following days:

    • February 20 10am-2pm
    • February 21 10am-2pm
    • February 22 10am-1pm

    Preferred Payment Type:


    Credit Card Information* (if applicable)
    Name On Credit Card:

    Credit Card Number:

    Expiration Date: Month: Year:

    Security Code:

    *Credit Card information will be processed once the application has been reviewed and approved.

    Comments:

    Please mail checks to: Southampton Cultural Center, P.O. Box 5008 Southampton, NY 11969
    Please make checks payable to Southampton Cultural Center