Registration
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Please fill out the form below to register for classes. If you have any questions please contact us a 858-780-1812 or send an e-mail to lessons@bertrandsmusic.com. If you signed up for our Headstart music program you can pay your registration fee online by clicking this link: http://www.bertrandsmusic.com/products/HeadStart-Registration-Fee-356530.html
How did you hear about us? *   Referral Name:         * - denotes required fields
Family Information:
Family Name:
Parent First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Home Address: *
City: * State: * Zip: *
Home Phone: *
 

Student #1 Information:
Student's First Name: * Last Name: *
Student Gender:  Birth Date: * (format=mm/dd/yy)  
Shirt Size:*
Bertrand's Account Number:

Classes (max 15)
Select Class #1: _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #2 Information:
Show-Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Shirt Size:*
Bertrand's Account Number:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #3 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Shirt Size:*
Bertrand's Account Number:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #4 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Shirt Size:*
Bertrand's Account Number:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   

Student #5 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Shirt Size:*
Bertrand's Account Number:

Classes (max 15)
Select Class #1: * _______________   
Select Class #2: _______________   
Select Class #3: _______________   
Select Class #4: _______________   
Select Class #5: _______________   
 
Enter your Full Name: *   
 
 
Comments:  

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