Shepherd Institute of Music

Semester Enrollment Form Semester 1_____Semester II______Semester III_______

Please Print                                                                               Date:_________________

Student Name: (Last)___________________ (First)____________________________

Address:________________________________________________________________

Home Phone ____________ Work Phone _____________ Cell Phone _______________

Date of Birth:_______________  email address:____________________________

Name of School (if applicable)____________________________________  Grade____

Occupation (adults)__________________________________________________

Department of Study: (Pick one)  Strings___ Band____ Vocal____ Keyboard____ Guitar__

Specific Instrument _________________

All Semester Classes are held on Monday afternoons and evenings.

Fall / Winter Term Fee (10 weeks) = $175 (plus $10 Registration fee to total $185 )

Please fill out the following Emergency Information:

Password____________________ (needed if other than Parent/Guardian pick up)

Emergency Contact: Name_____________________ Number ___________ Relationship_____________

Health Insurance_________________________ Policy #_________________________

Phone number of Insurance Company_________________

I agree for my child,___________________, to secure any emergency medical treatment, doctor’s care, or hospitalization, if needed, in the event of any serious illness, or accident. I understand that Shepherd Institute of Music, its Principals, and its Instructors and Teachers agree to make every reasonable effort to communicate with me immediately, But if it is impossible to locate me, I want Shepherd Institute of Music, its Principals, Instructors or Teachers to authorize whatever medical care, including surgery, If necessary, for the health of my child.

Parent/Guardian Signature__________________________________________

                                            (not required if student is over 18 years of age)

Date:________________________

List any special needs of student (allergies, diet,etc.)______________________

Use of Photos

I, the undersigned parent or guardian, do hereby give permission for photographs of my child to be used on flyers, Shepherd Institute of Music website, activity photo CD’s, or in displays promoting the Institute to the public. I understand that these photos will be used to promote the Shepherd Institute of Music and will be in no way exploited or misused by the Institute. This signed release is good for 2 years from the signeddate.

Guardian_____________________Date_______________________________________________________________________