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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