Music Makers

Enrollment Form

Member Information:

_________________________________       _________________         _____________          

Last Name                                                                 First Name                         Grade (Fall)

_________________________________________      __________________________

School Attending                                                                     Music Teacher's Name

Parent/Guardian Information:

________________________________________________      ___________________________

Last Name(s)                                                                               First Name(s)

___________________________________         _____________________     _______

Family Street Address                                                 City                                              Zip Code

______________________          _________________                       ________________

Home Phone #                                 Alternate/Cell Phone #                     Alternate/Cell Phone #

_______________________________      ___________________         _____________

Family/Parent/Guardian e-mail address        Emergency Contact Name     Phone #

Program Information:

__________________________                                   __________________________

First Choice Site                                                          Second Choice Site  

Enrolling in the program:

To enroll in the program, please fill out this form and send a non-refundable deposit of $100 (check made payable to KCC) to:

KCC - Music Makers

PO Box 50414       Kalamazoo, MI          49005-0414

We'll contact you by mail to confirm your enrollment, and give you more details of your specific class.