Summer Sampler Registration Form

Summer Music & Movement 2023

Thank you for your interest in registering for Summer Sampler: Music & Movement Classes.

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

2023 Summer M&M / Sampler Reg Form

Please complete the form below and make payment via PayPal. No PayPal account is required. You may use any credit or debit card. If you wish to pay by check, please send your check within 2 business days of submitting this form. Registration is not complete until payment is received.

How many children are you registering today?
- One child
- Two children
- Three children
Parent/Caregiver 1 Name*
First Last
Parent/Caregiver 1 Email*
Enter Email Confirm Email
Parent/Caregiver 1 Cell Phone*
Texting*
- YES, the School may send texts to this number.
- NO, I do not want to receive texts on this number.
Parent/Caregiver 2 Name
First Last
Parent/Caregiver 2 Email
Enter Email Confirm Email
Parent/Caregiver 2 Cell Phone
Texting
- YES, the School may send texts to this number.
- NO, I do not want to receive texts on this number.
Has your address changed?*
If you have been previously registered with Pakachoag Music School, has your address changed since you were last registered; or within the past 9 months?
- Yes
- No
- NA - I'm new to Pakachoag
Address*
Street Address City State ZIP Code
Who will attend class with child?
If another adult will attend with the child (ie. grandparent, nanny, etc.), please contact the office with their contact info.
- I will attend with child.
- Another adult will attend with the child.
Name of Accompanying Adult
First Last
Email of Accompanying Adult
Student 1 name*
First Last
Student 1 Date of Birth*
Student 2 name
First Last
Student 2 Date of Birth*
Will this child be over 9 months as of July 1*
- Yes
- No
Child #2 Quantity
Please add a 1 in the quantity field if your child will be over 9 months as of July 1.
Price: $62.00
Student 3 name
First Last
Student 3 Date of Birth
Will this child be over 9 months on July 1?*
- Yes
- No
Child #3 Quantity
Please add a 1 in the quantity field if your child will be over 9 months on July 1.
Price: $62.00
First Choice Class*
We do our best to place everyone in their First Choice. We will contact you if we need to assign you to your second choice.
- Monday, 9:30 am (Indoor) Sterling
- Tuesday, 9:30 am (Indoor) W. Boylston
- Wednesday, 9:30 am (Indoor) Auburn
- Thursday, 9:30 am (Indoor) Auburn
- Friday, 9:30 am (Indoor) All Saints, Worcester
- Saturday, 9:30 am (Indoor) Emanuel Lutheran, Worcester
Second Choice Class*
Please choose your SECOND choice class below. We do our best to place everyone in their First Choice. We will contact you if we need to assign you to your second choice.
- Monday, 9:30 am (Indoor) Sterling
- Tuesday, 9:30 am (Indoor) W. Boylston
- Wednesday, 9:30 am (Indoor) Auburn
- Thursday, 9:30 am (Indoor) Auburn
- Friday, 9:30 am (Indoor) All Saints, Worcester
- Saturday, 9:30 am (Indoor) Emanuel Lutheran, Worcester
Ethnicity for Grant Reporting - Primary Parent or Guardian*
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
- Other
- Prefer not to report
Ethnicity for Grant Reporting - Child One*
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
- Other
- Prefer not to respond
How did you hear about us / find 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
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 pay for an upcoming lesson, a $40 gift.
- Yes, I'd like to contribute to the average cost of a class, a $20 gift.
- No thank you.
Please review our Summer Program Policies at this link prior to completing registration, and confirm your acceptance below. Scroll down the summer registration page to find the "Summer Policies" section. Summer Registration & Policies
Receipt of Summer Health Policies Acknowledgement & Waiver of Liability COVID-19*
This includes policies related to absences, visiting the school, and safety/health as noted on the Summer Registration Web Page. Music Together & Health Policies: https://pakmusic.org/programs/summer-music/music-movement/. Waiver of Liability COVID-19: https://pakmusic.org/release-of-liability-covid-19/.
- I have read, understand, and agree to the Summer program policies. I have read, understand, and consent to the School's Waiver of Liability COVID-19.
Photo /Video Permission*
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.
- Yes
- No
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Payment Choice*
- Credit/Debit Card
- Check
Total Due
Please use the PayPal Checkout button below. You do not need a PayPal account. You will be taken to a window that includes a gray Pay with Credit or Debit Card button. If you are paying by check, click the blue Submit button and mail in your check to 10 Irving St 01609. Check can be made out to PakMusic. Thank you!
$0.00
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Payment Method

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Summer Music & Movement 2023

2023 Summer M&M / Sampler Reg Form

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