Enrollment Form
821 W. Jefferson Blvd. Mishawaka, IN. 46545 Ph. 574-255-9343

Please print out this form and mail it with a $50 deposit
(Hit print on your browsers window or choose file print)

Semester Fall____Spring____Summer____ Year________
STUDENT NAME ____________________________
Circle one Male/Female
ADDRESS ____________________________
CITY ____________________________
STATE ____________________________
ZIP ____________________________

HOME PHONE ________________WORK PHONE_______________

E-MAIL_______________________________

REFERRED BY: (Check any of the following) ____SIGN ____FLYER ____PHONE BOOK ____WEB SITE____WORD OF MOUTH

Name of person who refered you___________________________________________(if a student here)

IF UNDER 18 please fill out the following:

BIRTH DATE ______________ 19________ AGE ________

SCHOOL______________________________________________ GRADE ____

FATHER _____________________________ WORK PHONE _______________

MOTHER_____________________________WORK PHONE _______________

Please cross out below any times you are NOT available.

Monday 3:25 4:00 4:35 6:00 6:35 7:10 7:45
Tuesday 3:25 4:00 4:35 6:00 6:35 7:10 7:45
Thursday 3:25 4:00 4:35 6:00 6:35 7:10 7:45

{ ---} Check if you need to rent or purchase an acoustic guitar

Please return this form with a $50.00 tuition deposit to secure your place in a class. I understand the $50.00 is non-refundable and can only apply toward the semester for which I initially enroll and I also agree to pay the remaining tuition balance.

SIGNATURE _________________________________________DATE __________