OCTOBER 2017 PERLMAN COLLABORATION Student Name: Age: Instrument(s): Parent Name(s): Address: Home Phone: Cell Phone: E-mail: Emergency Contact Name: Emergency Contact Phone Number: Tuition for the October Perlman Collaboration is $100.00 Preferred Payment Type: ---Check By MailCredit Card Credit Card Information* Name On Credit Card: Credit Card Number: Expiration Date: Month: ---010203040506070809101112 Year: ---1718192021 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 631-287-5676stringsfestival@scc-arts.org