Community Music School

WIU Community Music School, String Orchestra Program Registration

Student Information
Student's Full Name:
Instrument Play:
Years Played:
Age:
Grade:
School:
Home Address:
Primary or Home Phone No.:
Secondary or Student Cell Phone No.:
E-Mail Address: (student email if applicable)
Parent Contact Information
Parent Name (First, Last)
Mom Contact Info:
Primary Contact Phone Number:
Cell Phone Number:
Email:
Dad Contact Info:
Primary Contact Phone Number:
Cell Phone Number:
Email:
Emergency Contact Info
Name:
Cell Phone Number:
Relation:
Parent Instruction and Confirmation Yes No Choose here if you give permission for pictures or name of student to be used for publicity in publication such as, but not limited to, newsletters, newspapers and magazines, and WIU brochures.
Parent signature for permission to enroll: Instruction: Type in your First Initial and Last Name Date:

Registration Information $75 per semester (Scholarships available if financial need) $150 per year (Scholarships available if financial need) Checks payable to: Community Music School at WIU Payment due on or before 1st rehearsal for participation Please mail (or bring to first rehearsal) completed form and check to: Dr. Richard Cangro School of Music Western Illinois University 1 University Circle, Macomb, IL 61455