Neighborhood Strings Registration Form (credit card payment)

Student Name*

Date of Birth*

Gender*

Girl
Boy
Other
Prefer not to say

Age*

Grade*

Parent 1 (or Guardian) Name*

First Last

Parent 2 (or Guardian) Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Please provide the best number to reach you.

Email*

What is your preferred method of contact from us?*

Email
Text
Phone
Mail

Emergency Information

Emergency Contact (other than parent or guardian)*

First Last

Relationship*

Emergency Contact Phone*

Emergency/Medical Information

Photo/Video Permission*

I give permission
I do not give permission

In the event that children in the program may be included in any newspaper, radio, television, internet publicity or other materials promoting the program, please indicate your preference. Submission of this form will serve as your signature.

Transportation Information

How will your child(ren) be leaving class?*

Parent/Guardian will pick up
Other approved family member/friend will pick up
Child will walk home

Are you willing to provide rides to other NS students for special events

Yes

Registration Fee*

Fall Semester $25, Full Year $50. if you do not wish to pay online, select “Pay by cash or check” and mail checks to: Worcester Chamber Music Society, 323 Main Street, Worcester 01608, or bring payment to the fall registration.

Fee Waiver Request

If you need to request a fee waiver, please check the box and do not make a payment at this time. Ariana will be in touch with you regarding your request

Payment*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Select “Credit Card” or “PayPal Checkout”.

Neighborhood Strings Student Registration Form

Emergency Information

Transportation Information