STUDENT/FAMILY INFORMATION
Are you a new student at Hochstein? Y
N
Are you, or any member of your immediate family, currently enrolled
at Hochstein Y N
Have you, or any member of your immediate family, previously registered
at Hochstein? Y
N
Student Name (M or F)
|
Phone (home)
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Address
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County
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City/State
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Zip
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E-mail (most frequently accessed)
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|
Date of Birth
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Age
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Race (for statistical purposes)
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Employer
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Occupation
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Phone (work)
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For Students under the age of 18, please complete the following:
School attending
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Grade (9/08)
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Father/Guardian Name
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E-mail
|
|
Employer
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Occupation
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Phone (home)
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Phone (work)
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Cell#
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Mother/Guardian
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E-mail
|
|
Employer
|
Occupation
|
|
Phone (home)
|
Phone (work)
|
Cell#
|
ENROLLMENT INFORMATION
Course or Ensemble Name
|
Day
|
Time
|
Fee
|
1.
|
|
|
|
2.
|
|
|
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3.
|
|
|
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For students enrolling in INSTRUMENTAL ENSEMBLES, please complete the following:
Instrument:
Private Teacher Name
Phone
Please list NYSSMA Solo information below:
If you have not participated in the NYSSMA Solo Fest, list title and composer of lesson book(s) or other music you have studied
| TITLE/COMPOSER
NUMERIC SCORE
LEVEL |
| |
| |
| |
Previous ensemble experience: (use additional space on reverse side, if necessary):
Sub total from above
|
$
|
Registration fee
(max 2 per family) |
$
|
Total enclosed
|
$
|
PAYMENT INFORMATION
O Check
or Money Order Enclosed
O Please charge my (please circle
one): VISA MasterCard
Credit Card # ____________________________________
Mail registration form to : Hochstein at Canandaigua, 435 East Street, Canandaigua, NY 14424
Cardholder’s signature________________________________
Expiration Date_________________
O Please automatically charge quarterly payments to the above credit card.