Music Academy South Registration Form

Please fill out, print and present this form in person at:
Music Academy South, Friendship Professional Center, 1241 S. Main St., Wake Forest, NC 27587

Student Information

Name:
Address:
City:
State:
ZIP Code:
Email:
Phone:

Student Age and School

Student is a: child adult
Date of Birth: / /
Age:
Parent's Name:
School Name:
Traditional Year-Round Home-School

Type of Lesson

Indicate the type of lesson you are interested in: Individual Group
Lesson Day 1st Choice: Time:
Lesson Day 2nd Choice: Time:
Special Considerations:

Registration Fees:

Annual Registration Fee (non refundable):
Book Deposit:
Group Lesson Monthly Fees (Piano & Guitar):
Individual Monthly Lesson Fees:

Payment

Fee Plan:
Method: Check Credit Card
Card Type:
Card Number:
Expiration Date: /
Card Holder Name: