Student Information: * information required
Student Name *:

  
Age *:


Parent or Guardian Name *:


Address *:


City*:    Postal Code*:

Phone:
Home* Business Cell

E-mail*:

Course Information - (Please check the appropriate box)*

Junior      Monday, July 7 - Friday, July 11       $225
Senior     Monday, July 14 - Saturday July 19    $400

As a parent or guardian, I am able to volunteer as a field trip chaperone or help with concerts.
I would consider billeting an out-of-town student.
I   allow - QCMC to use any photos or soundclips of me/my child for promotional purposes.

Private Lesson Information:
Instrument*:
  

Private Teacher*:


Phone*:   Number of Years of Lessons*:

Current Repertoire*:

Medical Alerts:
Allergies :
 
 
Medications:


Primary person to be notified:
Phone# :
   
Secondary person to be notified:
 Phone# :

Payment Information:
Deadline for Registration: June 6, 2008

Please enclose two cheques:
  (1) $150 non-refundable registration fee,
  (2) Post - dated cheque, June 20th 2008 for the remaining balance which is
        Junior: $225
        Senior: $400

Refund Policy: Students unable to attend a session for any reason will receive a refund, less the$150 registration fee, provided we are notified one month before the start of the camp. If notified less than one month prior we will attempt to refill your position from our waiting list. If we are successful, you will receive a refund less the $150 registration fee. If no replacement is found, there will be no refund issued.

Make Cheques Payable and send to:
Quiring Chamber Music Camp,
3187 Beacon Drive, Coquitlam, B.C. V3C 3W7

For Further Information:
Telephone: (604) 464 -1629

Note: To hold your place immediately fill out and submit this form. We must receive both of your cheques within 10 business days to reserve your place.