Northeast Iowa School of Music Online Registration

Registration

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Welcome to Northeast Iowa School of Music! Please complete the following registration form. If you only wish to look at available classes, please scroll down, add a student's first name and birthdate, and click the Select Classes button.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Ok to add to newsletter list?*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone *

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Special Needs (Leave blank if NONE)

Prefer Face-to-face or Zoom?*

OK to use image in media?*

Please click on the Select Class button below, then choose the class.

After clicking the Select Class button, use the magnifying glass in the top left corner to filter for a specific session, instructor, instrument, or day of the week.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Special Needs (Leave blank if NONE)

Prefer Face-to-face or Zoom?*

OK to use image in media?*

Please click on the Select Class button below, then choose the class.

After clicking the Select Class button, use the magnifying glass in the top left corner to filter for a specific session, instructor, instrument, or day of the week.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Special Needs (Leave blank if NONE)

Prefer Face-to-face or Zoom?*

OK to use image in media?*

Please click on the Select Class button below, then choose the class.

After clicking the Select Class button, use the magnifying glass in the top left corner to filter for a specific session, instructor, instrument, or day of the week.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Special Needs (Leave blank if NONE)

Prefer Face-to-face or Zoom?*

OK to use image in media?*

Please click on the Select Class button below, then choose the class.

After clicking the Select Class button, use the magnifying glass in the top left corner to filter for a specific session, instructor, instrument, or day of the week.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

School

Grade Level

Special Needs (Leave blank if NONE)

Prefer Face-to-face or Zoom?*

OK to use image in media?*

Please click on the Select Class button below, then choose the class.

After clicking the Select Class button, use the magnifying glass in the top left corner to filter for a specific session, instructor, instrument, or day of the week.

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

How I Plan To Pay*

Please fill out ONE of the following Payment Methods

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

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

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

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)