WEST NEIGHBOURHHOOD HOUSE MUSIC SCHOOL

248 Ossington Ave., Toronto, ON M6J 3A2 Tel. (416) 532-4828 x127 Fax. (416) 532-8739

E-Mail- Web site www.westnh.org

Registration Form 2015-2016

Student’s first name / Last Name
Address/Apt. / Postal code
email / Home #
Only give email address if you check it regularly / Cell #
Parent name / Parent name
Student’s date of birth / Language spoken at home
School / Grade
Instrument(s) (please list)
Group classes- CTKids choir Adult choir / (Please circle)
Other info (medical, learning challenges etc)
Choice #1 day/time/teacher (Please note we try to meet all requests but cannot guarantee your choices.)
Choice #2 day/time /teacher
FOR OFFICE USE ONLY:
Currently renting instrument from WNH? Yes_____ / Description/ rental date:
Instrument(s) / Day/Time
Length / Teacher

****I understand that my child’s photograph may be taken during Music School events and that his/her photograph or likeness may be used in West Neighbourhood House publications or print or video reports dealing with West Neighbourhood House, without remuneration to me or my child. I also understand that West Neighbourhood House doesn’t provide supervision and children under the age of 12 must be accompanied by an adult or older sibling at all times.

I have read the above statement (parent/guardian signature)

______Date ______

I give permission for pictures to be taken and used by West Neighbourhood House (signature)

______Date______

Fee Code ______amount per week ______savings ______

POI rec’d ______Sign off for subsidy ______

Fall Term / Winter Term / Spring Term / Summer Term
per lesson $ / per lesson $ / per lesson $ / per lesson $
# of lessons / # of lessons / # of lessons / # of lessons
Total fees $ / Total fees $ / Total fees $ / Total fees $
Paid $ / Paid $ / Paid $ / Paid $
Date / Date / Date / Date
Receipt # / Receipt # / Receipt # / Receipt #
amount / Ca/Ch / date / Receipt # / balance