Mount Olivet School of Music Band and Orchestra in Partnership with Burroughs Community School
Band and Orchestra 2011-12

(4th & 5th Grade)

All Classes are held Thursdays beginning September 22 from 3:45-5:15pm

Participant Information

* This Registration is for

Band

Orchestra

* First Name

* Last Name

* Gender

Male

Female

* Birthdate: month/day/year

* Grade as of September 1, 2011

* Street Address

* City

* State

* Zip Code

* Phone Number

* Email Address (All announcements will be sent to this email address)

Please email me updates

If your child has any special needs or significant medical information, please list it here:

Parent Information

* First Name

* Last Name

Contact Method

Number

Alt. Contact Method

Alt. Number

Parent #2

Contact Method

Number

Alt. Contact Method

Alt. Number

Please provide us with an emergency contact who can be contacted and/or is authorized to pick-up your child in case a parent/guardian is unavailable.

* EMERGENCY CONTACT NAME

* Relationship to child

* 1st Contact Method

* Number

Alt. Contact Method

Number

* Indicates Response Required