Application Form July 2017

Deadline to register: Monday June 19

Please complete the form BEFORE making a payment.  Remember to select payment option and click “send e-mail” button at bottom of form. You can pay your registration fees through our Paypal account or by mailing a cheque to the address below.



Student Information

Student Name *
Age *
Parent or Guardian *
Address *
City *
Postal Code *
Phone (no spaces) *
Cellphone (no spaces)
Email *

Private Lesson Information

Instrument *
Private Teacher *
Phone (no spaces) *
Number of Years of Lessons *
Current Repertoire *

Medical Alerts

Allergies
Medications
Primary person to be notified
Primary Phone # (no spaces)
Secondary Person to be notified
Secondary Phone # (no spaces)

Payment Information

Juniors (ages 5-11): $400
Seniors (ages 12-20): $500

Please make cheques payable to the Quiring Chamber Music Camp. There will be no refunds after June 23.  Bursaries are available with the submission of a 2016 tax return.

Make cheques payable and send to:
Quiring Chamber Music Camp,
2050 Monterey Ave.  Coquitlam, BC V3K 6T8

For Further Information:
Telephone: (604) 939-9313

Note: To hold your place, fill out and submit this form. We must receive your cheque within 10 business days of application submission or before June 19 (which ever comes first).

Payment Options: choose one *
 Mail a cheque 
 Pay through Paypal 
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Pay by Paypal

Once you have completed the form above please follow this link to pay with Paypal