Student Name:



    2020 / 2021 NYSSMA level:

    Most Recent Piece Studied:

    Private Teacher's Name:

    We would like students to prepare a small recording of up to 5 minutes worth of music that represents your playing. Prepare selections of music that you can play with confidence, avoiding ones that are too challenging or too new to demonstrate your abilities.

    *Recordings should not be more than 6 months old.

    **Recordings are NOT an audition, they are strictly to help us place you into chamber groups.

    Please paste your recording links here or email them to

    Parent Name(s):


    Home Phone:

    Cell Phone:


    Emergency Contact Name:

    Emergency Contact Phone Number:

    Tuition for 2020: (please choose one option)

    Need-based scholarships are available. Please fill out this form and contact Kirsten Lonnie, Executive Director of Southampton Cultural Center at 631-287-5676 or to apply. Scholarships are limited and will be awarded on a first come, first served basis as funding allows. Please apply as early as possible for consideration. If you would like to make a donation toward our scholarship fund, please click on the donate link above.

    Preferred Payment Type:

    Credit Card Information*
    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.


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