GENERAL REGISTRATION FORM
O   Registration for Rochester Campus     O   Registration for Canandaigua Campus

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 (h/c)
Address	County
City/State	Zip
E-mail (most frequently accessed)
Date of Birth	Age
Race (for statistical purposes)	Employer
Occupation	Phone (w)

For Students under the age of 18, please complete the following:

School attending	Grade (9/10)
Father/Guardian Name	E-mail
Employer	Occupation
Phone (h)	Phone (w)	(c)
Mother/Guardian	E-mail
Employer	Occupation
Phone (h)	Phone (w)	(c)

ENROLLMENT INFORMATION

Course or Ensemble Name	Day	Time	Fee
1.
2.
3.

                                                                                                                                                                                                                   

For students enrolling in INSTRUMENTAL ENSEMBLES, please complete the following:

Instrument:                                                                                Individual Instructor's Name:

Instructor Email                                                                                 Instructor 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 # __________________________________3 digit security code _ _ _ (located on back)

        Cardholder’s signature________________________________Expiration Date_________________

O    Please automatically charge quarterly payments to the above credit card.

Mail to:

Hochstein School of Music & Dance, 50 N. Plymouth Ave., Rochester, NY 14614 or

Hochstein at Canandaigua, 435 East St., Canandaigua, NY 14424