Judith G. Wharton Music Center - Fall 2009 Registration Form
Student Information
STUDENT NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL:
SCHOOL:
CITY:
GRADE:
BIRTHDATE (CHILDREN ONLY):
MALE  FEMALE
  NEW STUDENT    RETURNING STUDENT
 
The following information is optional and for statistical purposes only
AFRICAN AMERICAN   ASIAN   HISPANIC   NATIVE AMERICAN   WHITE/CAUCASIAN   OTHER
 
Complete the following information if the student is under 18 years old
PARENT or GUARDIAN #1
  MR.  MRS.  MS.  DR.  
PARENT/GUARDIAN NAME:
OCCUPATION/TITLE:
EMPLOYER:
HOME PHONE:
WORK PHONE:
CELL PHONE:
EMAIL:
EMERGENCY CONTACT PERSON:
EMERCENGY CONTACT PHONE:
(OPTIONAL) PARENT or GUARDIAN #2
  MR.  MRS.  MS.  DR.  
PARENT/GUARDIAN NAME:
OCCUPATION/TITLE:
EMPLOYER:
HOME PHONE:
WORK PHONE:
CELL PHONE:
EMAIL:
EMERGENCY CONTACT PERSON:
EMERCENGY CONTACT PHONE:
   
Lesson/Class Information
HOW DID YOU HEAR ABOUT WMC?
   
INSTRUMENT TEACHER (IF KNOWN) LENGTH OF LESSON TUITION
 30 MIN. 45 MIN.  60 MIN.
 30 MIN. 45 MIN.  60 MIN.
 30 MIN. 45 MIN.  60 MIN.
CLASS DAY/TIME TUITION/MATERIALS FEE
     
Tuition Totals
  TOTAL (TUITION/MATERIALS FEE):
  PAYMENT PLAN FEE:
EARLY REGISTRATION DISCOUNT (BY AUGUST 14, 2009):
REFERRAL DISCOUNT CODE:
  REGISTRATION FEE ($50 STUDENT/$75 FAMILY):
  TAX DEDUCTABLE DONATION:
  GRAND TOTAL:
  AMOUNT OF THIS PAYMENT:
     
Terms and Conditions

By checking the box below, your digital signature acknowledges that you fully understand and agree to abide by all terms and conditions specified on the Payment and Procedures pages of the WMC 2008-2009 Course Catalog or the same on the whartonmusiccenter.org website.

Photography Waiver: From time to time, WMC may engage the services of a professional photographer to take pictures of lessons, classes, camps and performances. WMC reserves the right to use these photos for publicity purposes such as WMC's course catalogs, website, email blasts and brochures. By digital signing this registration form you are granting WMC permission to use any photos taken on its premises for marketing purposes. This applies unless a parent or guardian submits a written, dated request that their child's image not be used. Names of persons depicted in photos will not be used unless specific permission is given.

Check here to digitally sign and acknowledge acceptance of the above terms and conditions (required)
Payment Information
I WILL PAY THE TOTAL DUE 
I AM REQUESTING A PAYMENT PLAN (PRIVATE LESSONS ONLY)
 
Click Here to submit this form and proceed to the payment page