Phoenix Conservatory of Music Online Registration

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Thank you for taking the opportunity to increase your musical skill sets and join our community!

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Referral Information

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Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info/Who is allowed to pick up the student(s)*

Number of People in Household*

Annual household income *

Ethnicity*

Preferred Days*

Preferred Times*

Contact #1

Contact #1 First Name*

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Type*

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Contact #2

Contact #2 First Name

Last Name

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Home Phone

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Student #1

Student's First Name*

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Student Gender*

Birth Date*

Additional Info

Student Email

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Grade Level*

Disabilities (Leave blank if NONE)

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Student's First Name*

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Student Gender*

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Student Email

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Grade Level*

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Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

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Can student leave facility?*

Ethnicity*

Preferred Instrument*

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Student #3 (Show-Hide Details)

Student's First Name*

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Can student leave facility?*

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Student's First Name*

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Student Email

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Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Can student leave facility?*

Ethnicity*

Preferred Instrument*

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Enroll in Classes

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Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Can student leave facility?*

Ethnicity*

Preferred Instrument*

Homeroom Teacher's Name

Enroll in Classes

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Registration

Referral Information

Family Information (Demographic information is collected for funding purposes only)

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

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Student #2 (Show-Hide Details)

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Student #3 (Show-Hide Details)

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Questions or Concerns

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