Registration
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Welcome to New Jersey School of Music! Please complete the following form.
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Referral Information
How did you hear about us?
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Drive-By
Here as a Child
Internet Search
Lives in Town
Other
Referral
Returning Family
Sibling on Schedule
Walk-In
Website
Referral Name
Family Information
Last Last Name
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Where do you live?
Home Address
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City
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State
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AK
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CT
DC
DE
FL
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ID
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KY
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MA
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ME
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MO
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PA
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SC
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TN
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UT
VA
VT
WA
WI
WV
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PR
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Zip
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Primary Phone
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Additional Info
Medford or Cherry Hill
In Person or Virtual
Contact #1
Contact Info First Name
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Last Name
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Type
Father
Grandparent
Mother
Other
Parent
Self
How Can We Contact You?
Home Phone
Cell #
*
Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Contact #2
Additional Contact Info First Name
Last Name
Type
Father
Grandparent
Mother
Other
Parent
Self
How can we contact you?
Home Phone
Cell #
Email
(Emails are kept confidential)
Confirm Email
Student #1
Student's First Name
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Last Name
*
Student Gender
Female
Male
Other
Birth Date
*
Additional Info
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Instrument Type/Music Therapy
*
Style
Preferred Day(s)
*
Preferred Time(s)
*
Estimated Start Date
*
Student #2
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Student's First Name
*
Last Name
*
Student Gender
Female
Male
Other
Birth Date
*
Additional Info
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Instrument Type/Music Therapy
*
Style
Preferred Day(s)
*
Preferred Time(s)
*
Estimated Start Date
*
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
Female
Male
Other
Birth Date
*
Additional Info
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Instrument Type/Music Therapy
*
Style
Preferred Day(s)
*
Preferred Time(s)
*
Estimated Start Date
*
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
Female
Male
Other
Birth Date
*
Additional Info
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Instrument Type/Music Therapy
*
Style
Preferred Day(s)
*
Preferred Time(s)
*
Estimated Start Date
*
Student #5
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Student's First Name
*
Last Name
*
Student Gender
Female
Male
Other
Birth Date
*
Additional Info
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Instrument Type/Music Therapy
*
Style
Preferred Day(s)
*
Preferred Time(s)
*
Estimated Start Date
*
Add Another Student
Required Policies
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I Agree to All of the Above
Enter your Full Name
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November 21, 2024
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