registration_form_GIRL

STUDENT NAME:__________________________Age:____
Instrument:__________Experience (yrs, mo):____

Parent/Guardian Name:_________________________________
Mailing Address:________________________
City:________________STATE:____________ZIP:___________
Home phone:____________________________________________
Cell phone:______________________________________________
Work Phone:____________________________________________
Emergency Name:________________________________________
Emergency phone:________________________________________
EMAIL:_________________________________________________

Rules & Regulations:
Classes are open to registrants until the day before scheduled to begin. All applicants must pay tuition in full at
the time of registration. There is 50% cancellation refund prior to the start of classes. After that, all tuition is
non-refundable. In addition, camps and classes are not transferable and will not be credited to your account
under any circumstances. All students are required to fulfill any performance dates.

I have read and agree to the tuition, course curriculum, and cancellation policies of Rock Star Band Camp. I understand that
Rock Star Band Camp is not responsible for any loss or damage to personal items. I also understand that any damage to
the studio facility, including damage to equipment and instruments, as well as personal injury incurred on premises is the
sole responsibility of the client. I give permission for the publication of photographs, videos, and recordings of my child at
Rock Star Band Camp.
Parent Signature:_________________________________Date:______________

Please mail forms to: Rock Star Band Camp PO Box 242, Westhampton Beach, NY 11978.
ATTN: GIRL GROUP

PAYMENT INFORMATION: GIRL GROUP cost is $125 for (6) week program.

My check is enclosed for $___________________________________________
Make checks payable to: ROCK STAR BAND CAMP

Or

I would like to pay with my Credit Card. RSBC accepts:
CARD TYPE (circle one)        CARD NUMBER        Exp. Date mm/yy
Visa / MasterCard / Discover        _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ _        ____ / ____
American Express        _ _ _ _ - _ _ _ _ _ _ - _ _ _ _ _        ____ / ____

                                                                   Security Code (3 or 4 Digits): __________
Charge Amount (US $): __________.___
Cardholder Signature/Charge Authorization:__________________________________
INVOICE will be mailed. Thank you for choosing Rock Star Band Camp!

copyright 2010 Rock Star Band Camp