2009-2010 Registration Form

Please complete this form and mail to:
      University of Delaware
      Community Music School
      Amy E. du Pont Music Building
      Newark, DE 19716

(Make checks payable to the University of Delaware)



Date______________        Semester:  ___ Fall      ___ Spring

____ New     ____ Returning          ___ Male      ___ Female

Student's Name______________________________________________________

Address_____________________________________________________________

City_______________________________ State_________ Zip______________

Birthdate________________                         Age_______________

Grade_________ School_______________________________________________

Instrument _________________________________________________________

Previous/Requested Teacher _________________________________________

Parent/Guardian Name________________________________________________

Home Phone___________________________________________

Work Phone___________________________________________

Prior Experience ___________________________________________________

Email Address________________________________________

Course Name / Private Instruction Teacher            Tuition

_______________________________________________      $______________

_______________________________________________      $______________

_______________________________________________      $______________

Registration Fee: $30.00 per ___ person(s)           $______________
(waived before August 15)

Materials Fee (if applicable)                        $______________

TOTAL                                                $______________

FULL TUITION AND ALL FEES ARE DUE UPON REGISTRATION.

Makeups cannot be given for lessons or classes missed by the
student without proper notice.  I understand and accept the
conditions of registration described in the catalog.

Signature __________________________________________________________


Method of Payment (Circle One)

Check     Cash      Visa      MasterCard       Discover      Am Ex

Make checks payable to: University of Delaware

I authorize the UD Department of Music to charge

account number: __________________________________________________

Expiration_______________

Total amount to be charged________________

Print Name as on Card_____________________________________________

Signature_________________________________________________________