FEBRUARY 2017 WORKSHOP REGISTRATION Student Name: Age: Instrument(s): ---ViolinCelloChamber Ensemble 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: ---Check By MailCredit Card Credit Card Information* (if applicable) Name On Credit Card: Credit Card Number: Expiration Date: Month: ---010203040506070809101112 Year: ---1617181920 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