Application form – Summer 2013

Deadline  Friday June 21

You can pay your registration fees by mailing a cheque or through our Paypal account. Please fill out the form below BEFORE making a payment. If you have any questions or problems please email us.



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 July 1. Scholarships are available with the submission of a 2012 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 immediately, fill out and submit this form. We must receive your cheque within 10 business days or before June 21 (which ever comes first) to reserve your place.
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