Summer Rock School Registration Form

Please fill out the form fully and send it to me by pushing the submit button.

Student Name:

Parents Name:

         Address: 

      Address 2:

               City:

             State:

        Zip Code:

Home Phone:

Cell Phone:

E-mail address:

    Student Age:

Sex/ Male            Female

List instrument(s) you play:

What Level do you consider your self?

Beginner      Intermediate     Advanced

Vocal Yes          No         Maybe

Please Check Styles of music you like.

Rock      Pop     Country     Metal     Alternative

Desired Band Members

(others who are signing up):

Is rehearsal time flexible?      Yes      No

If No, list preference:

Tuition

You may pay by check or we also take Visa & Mastercard

to pay with a credit card, go to http://shop.firestationseven.com/

Checks should be made out to Scott Miller

and mailed to:

13665 Pasque Flower Ct.

Keystone SD 57751

CHOOSE ONE PLEASE

                                                     Full Tuition $300.00

                              Monthly Tuition $110.00 (3 months)

By submitting this form I agree to the following disclaimer.

Scott Miller and/ or family members will not be held

responsible for injury or loss of any equipment during

either the rehearsals or the concert.

Review your entries and then push the submit button to send

As soon as I receive this, I will contact you via e-mail