Student Information: * information required
Student Name *:

  
Age *:


Parent or Guardian Name *:


Address *:


City*:    Postal Code*:

Phone:
Home* Business Cell

E-mail*:

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:
Juniors (ages 5-11): $350
Seniors (ages 12-20): $450
Please make cheques payable to the Quiring Chamber Music Camp. There will be no
refunds after July 2. Scholarships are available with the submission of a 2009
tax return.

Make Cheques Payable and send to:
Quiring Chamber Music Camp,
87 Mundy Street, Coquitlam, B.C., V3K 5L5

For Further Information:
Telephone: (604) 524-8898

Note: To hold your place immediately, fill out and submit this form. We must receive your cheque within 10 business days or before June 25 (which ever comes first) to reserve your place.