Community Music School

WIU Community Music School, Family Music Classes Registration

Child's Name
Age:
Student Information
Home Address:
Home Phone:
Parent/Guardian Contact Information
Parent/Guardian Name: (First, Last)
Mom Home Phone:
Mom Mobile Phone:
Mom Work Phone:
Mom E-mail:
Dad Home Phone:
Dad Mobile Phone:
Dad Work Phone:
Dad E-mail:
Emergency Contact Information
Name:
Relationship:
Phone/Cell:
Parent Instructions and Confirmation
Check here if you do not give permission for pictures or name of student to be used for publicity in publications such as, but not limited to, newsletters, newspapers and magazines, and WIU brochures.
Parent signature for permission to enroll: Date:
Select to Register: A Bushel and a Peck (Family Class) - Toddlers through preschool with a parent Thursdays, 6:00PM - 6:45PM $115 per family/12 Weeks - Browne Hall, Room 205 Mixed-aged with a parent
Registration information Checks payable to: Community Music School Payment due on or before 1st class for participation Please bring completed form and check to the instructor or mail registration form and check to: Richard Cangro, CMS Director Western Illinois University 1 University Circle Macomb, IL 61455

If you need the content displayed on this website in an alternative format,
please contact Khaing Saw at KK-Saw@wiu.edu or call 309-298-2619.