ARKANSAS CENTER FOR MUSIC EDUCATION REGISTRATION FORM

(Please complete a separate form for each student, including adults.)

Date: ________________

Student’s Name: ___________________________________________ Date Of Birth: _____/_____/_____

First Last

Parent’s Name: ____________________________________________________________

E-mail: _____________________________________________

Street Address: _________________________________________________________________

(Please include

zip code) _________________________________________________________________

Mailing Address: ________________________________________________________________

(if different than above)

________________________________________________________________

Home Phone: ________________________ Cell or Work Phone: ______________________

Has student had any type of musical instruction or training by a professional? q Yes q No

If yes, list type of instruction (voice, piano, guitar, string instrument, etc.), length of time taking instruction, and instructor.

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Student’s Current Grade Level: ______________

Where does student attend school? _________________________________________________

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Please check the class(es) below this is student is registering for (Note: some classes may be closed to enrollment. Please call for information.)

q Pre-K q K5 – 2^nd Elementary q 3^rd – 5^th Elementary q 6^th – up General q Band q Voice class

q Pee Wee Orchestra q Orchestra

Does student have siblings that will also be participating in any of the music classes offered by ACME?

q Yes q No

If so, how many siblings are participating? _________________________________________________

________________________________________________________________________________________

over

Does student have a family member (parent, sibling, grandparent) not attending ACME classes that plays an instrument? q Yes q No

If yes and they would be interested in playing with an ACME ensemble or playing for a class, list their name and instrument played. (Please obtain permission from any person, even family, before listing their information.)

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Does the student have any special needs or difficulties (i.e. ADHD, learning disabilities, etc.)? (Note: We ask this so that we are not left finding out through trial and error that a child may have a difficulty. By knowing in advance, we may be able to modify lessons to assist such children.)

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_______________________________________________/___________________

Parent Signature / Date