Summer First Steps Registration Form | Pakachoag Music School

Summer 2023

Thank you for your interest in registering for a Summer Suzuki: First Steps.

If you need assistance completing this form, please contact the office at 508-791-8159 or email info@pakmusic.org.

Thank you.

2023 Summer Suzuki First Steps

"*" indicates required fields

How many children are you registering today?*

1 student ($172)

2 students ($344)

Student 1*

First Last

Student 1 Date of Birth*

Student 2

First Last

Student 2 Date of Birth

Parent/Caregiver 1*

First Last

Parent/Caregiver 1 Email*

Parent/Caregiver 1 Phone*

Address*

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

Parent/Caregiver 2

First Last

Parent/Caregiver 2 Phone

Parent/Caregiver 2 Email

Hidden

Are you flexible around participation?*

While we will make a decision for in-person vs. online based on government guidelines and local circumstances as we move toward July, your response here will help us anticipate if we can run this class.

Whether In-Person or Online, we will participate.

We will only participate if in-person

We will only participate if offered remotely

Not sure; depends on circumstances as we move toward July

Hidden

Desired Class Child 1

Violin: In-Person, Wednesdays in Worcester with Amy Matherly

Violin: In-Person, Thursdays in West Boylston with Madalyne Cross

Hidden

Desired Class Child 2

Violin: In-Person, Wednesdays in Worcester with Amy Matherly

Violin: In-Person, Thursdays in West Boylston with Madalyne Cross

Hidden

2nd Class Choice Child 1 and/or Child 2

If your desired class has already filled, will you consider either or both...

Either location, as space permits

Cello rather than violin

I have no 2nd class choice

Think you might need to miss a week?

If you anticipate possibly missing a week or two due to vacation plans, please check here and let your teacher know at your first class meeting. We'll ask you to register for a 30 minute private lesson (before or after vacation) at the current lesson rate.

Yes, I may miss 1 or 2 class meetings.

Ethnicity for Grant Reporting - Student 1*

Your response is appreciated and is helpful when reporting to grantors. Information is confidential and gathered for reporting purposes only.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

Two or More Races

White

Prefer Not to Respond

Other

Ethnicity for Grant Reporting - Student 2

Your response is appreciated and is helpful when reporting to grantors. Information is confidential and gathered for reporting purposes only.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

Two or More Races

White

Prefer to Not Respond

Other

Ethnicity for Grant Reporting - Parent/Caregiver 1

Your response is appreciated and is helpful when reporting to grantors. Information is confidential and gathered for reporting purposes only.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

Two or More Races

White

Prefer Not to Respond

Other

Photo/Video Consent*

Do you give Pakachoag Music School permission for yourself and/or your child(ren) to be photographed and/or videotaped during school functions for school purposes and for such photos or videos to be used commercially by the school, including postings on the School web site. We do not post names publicly (but may make a specific request, individually, if so desired).

Yes

Other

Please review our Summer Program Policies at this link prior to completing registration, and confirm your acceptance below. Scroll down to find the "Summer Policies" section. Summer Registration & Policies

How did you find us?

If this is your first time registering with Pakachoag, how did you find out about us?

Word of Mouth: Friend/Family Referral

Word of Mouth: School Teacher Referral

Online: Social Media (Facebook, Instagram, Etc.)

Online: Search Engine (Google, Bing, Etc.)

Print Media: Newspaper, Concert Program, Etc.

Print Media: Brochure, Postcard, Etc.

Attended a Pakachoag Performance or Event

Other

Payment Method*

Please indicate your payment method preference. Checks should be made payable to PakMusic and sent within 2 days of submitting this form.

I'll make payment with a debit/credit card or PayPal account. PayPal account NOT needed. Use PayPal button.

I will mail in a check within 2 days made out to PakMusic. Total is below.

Support a Student in Need Option*

Would you like to make a donation to the Music Matters program for children/youth of low income? Thank you.

Yes, please add a $10 donation to my final payment.

Yes, I'd like to contribute to the average cost of a class, a $20 gift.

Yes, I'd like to pay for an upcoming lesson, a $40 gift.

No thank you.

Total

Section Break

Payment Method

CAPTCHA

This field is for validation purposes and should be left unchanged.