Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #1 Name *

First Name

Last Name

Parent Guardian #1 Phone *

(###)

###

####

Parent/Guardian #2 Name

First Name

Last Name

Parent Guardian #2 Phone

(###)

###

####

I would like to be considered for a scholarship to attend: *

Private Lessons

Rock Week Summer Camp (June 9-13)

Worship Week Summer Camp (June 23-27)