Maine Academy of Modern Music Online Registration

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Thank you for choosing to rock with the Maine Academy of Modern Music! We are thrilled that you are here.

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Referral Information

How did you hear about us?*

Referral Name

Family Information

Family last name(s): Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Additional Info

Additional Emergency Contact:

Family's primary language:

Coupon code:

Contact #1

Contact #1 First Name*

Last Name *

Relation to student:*

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

Relation to student:

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Gender Identity / Pronouns:*

Birth Date*

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor / Phone Number*

Instrument to Learn/Play:*

Favorite Bands/Artists/Genres:*

Availability:

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity / Pronouns:*

Birth Date*

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor / Phone Number*

Instrument to Learn/Play:*

Favorite Bands/Artists/Genres:*

Availability:

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity / Pronouns:*

Birth Date*

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor / Phone Number*

Instrument to Learn/Play:*

Favorite Bands/Artists/Genres:*

Availability:

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity / Pronouns:*

Birth Date*

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor / Phone Number*

Instrument to Learn/Play:*

Favorite Bands/Artists/Genres:*

Availability:

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity / Pronouns:*

Birth Date*

Cell #

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor / Phone Number*

Instrument to Learn/Play:*

Favorite Bands/Artists/Genres:*

Availability:

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

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

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

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Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

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Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

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