East Dallas Children's Music

Spring 2008 Secure Online Registration Form

For Adult Keyboard Classes

This form is protected by 128 Bit Secure Socket Layer Technology

* indicates required field

Name

*First Name *Last Name

*Address1

Address2

*City State *Zip

*Home Phone

Cell Phone 1

Cell Phone 2

Work Phone

*E-mail

 

*Please select a class and time:


*Please select an alternate class and class time, in the event that your first choice is unavailable:

*Are you new to our studio, or returning?

If you are new to our studio, please tell us how you found out about us, or whom we may thank for referring you:

What is your musical background (list any instruments played)?

Payment Arrangements:


to our mailing address: East Dallas Childrens Music, 942 Bridget Ln, Dallas, TX, 75218

By clicking on the "Submit" button, acknowledge that I have read and understood the East Dallas Children's Music policies and agree to the terms within. I wish to register for the class indicated. I understand that photographs taken in class may be used without financial compensation, unless otherwise indicated in writing. Submission of this registration indicates my agreement that I will not hold East Dallas Children's Music responsible for any loss, damages or injury incurred directly or indirectly from participation in the East Dallas Children's Music program or class. If paying by credit card, submission of this registration also constitutes authorization to charge said card.