Neighborhood Music School Online Registration

Registration

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NOTE: Once we receive this registration form we will contact you to enroll your student(s). You are welcome to enter your payment information if you'd like us to keep it on file. However, you will not be billed any fees at this time. In order to submit application you need to agree to all the policies. If you'd like to opt out of the Photo Release Policy please indicate that on the registration.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Address

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone

Additional Info

Emergency Contact Info (Not Contact #1 or #2)

Contact #1

(students over 18 add yourself as contact) First Name*

Last Name *

Relation to Student*

How Can We Contact You?

Home Phone

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

(Over 18 no need to add parent information) First Name

Last Name

Relation to Student

How can we contact you?

Home Phone

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

School

Grade Level

Disabilities or Special Needs

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

School

Grade Level

Disabilities or Special Needs

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

School

Grade Level

Disabilities or Special Needs

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

School

Grade Level

Disabilities or Special Needs

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

School

Grade Level

Disabilities or Special Needs

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

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Registration

Referral Information

Address

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

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)