Community Music School
Spring 2018Registration Form
Please complete both sides, sign below, and attach the registration/class/ensemble fee.
E-MAIL ______How did you hear about CMS? ______
1.) Last Name______First Name ______MI ____
Date of Birth ______Age ______ Male Female School ______
2.) Last Name ______First Name ______MI ____
Date of Birth ______Age ______ Male Female School ______
Home Phone ______Cell Phone ______
Home Address ______City ______Zip ______
For Non-Adult Students
Parent’s(Guardian’s) Name ______
Address and Phone (if different from student’s) ______
Occupation ______Employer ______
Work Phone ______May we call you at work? yes no
Parent’s (Guardian’s) Name ______
Address and Phone (if different from student’s) ______
Occupation ______Employer ______
Work Phone ______May we call you at work? yes no
Emergency Contact ______Phone ______
For Adult Students
Occupation ______Employer or School ______
Work Phone ______May we call you at work? yes no
I have read and agree to abide by the CMS Policies and Procedures.
Unless advised otherwise in writing, your signature gives CMS permission to photograph you or your child and to use the image(s) in our print materials, website and social media. .
X______
SIGNATURE of Student or Parent/Guardian (if student is under 18)Date
Billing information: (please print)
Send bills to: Mr. Mrs. Ms. ______
Address (if different from student’s) ______
Please attach the non-refundable annual registration fee of $20 per student (no registration fee for class & ensemble students).
To charge your VISA, AMEX, Discover or MasterCardfor the registration fee or class/ensemble tuition, please complete the information below. If you’d like your monthly installment billed to this card, please initial here: ______
CARD # ______Expiration Date ______$ Amount ______
Cardholder’s Signature ______3- Digit CVV ______
Would you like to make a donation to CMS using your credit card?If so, please write amount on the appropriate line below.
Friends of CMS (to support general operating): $____ CMS Scholarship: $____
To be considered for financial aid, please submit a Financial Assistance Form with proof of household income.
Beneficiary Statistics Required by Funding Sources
Information on this form is confidential. Statistics are reported only in aggregate/total.
Ethnic/Racial BackgroundGross Family Income
1) Caucasian 2) Black/African-American 1) Below $9,999 2) $10,000 – 19,999
3) Latino/Hispanic 4) Asian 3) $20,000 – 29,999 4 $30,000 – 39,999
5) Native American 6) Arab 5) $40,000 – 49,999 6) $50,000 +
7) Other (or mixed): What ?______
Community Music School admits students of any race, color, gender, national or ethnic origin, sexual orientation and religious belief to all the rights, privileges, programs and activities generally accorded or made available to students at the School. It does not discriminate on the basis of race, color, gender, national or ethnic origin, sexual orientation or religious belief in the administration of its educational policies, admissions policies, scholarship programs and other school-administered program. CMS is proud to be a member of the National Guild for Community Arts Education and the Greater Buffalo Cultural Alliance, and a donor-designated agency of United Way of Buffalo and Erie County.
415 Elmwood Avenue Buffalo, New York 14222 Phone: (716) 884-4887 Fax: (716) 884-7529
Buffalo Clarence Larkin Lockport Snyder West Seneca
PRIVATE LESSONS
2017-18 lessons may be scheduled now with Jennifer Guillow. Student(s) will be matched with an instructor within two weeks of registering for lessons. Your monthly payment will be determined by the lesson day. Your firstpayment must be received at least 1 day before the first scheduled lesson.
What would you like to study (piano, voice, clarinet etc.)? ______
What length lesson? 30 minutes 45 minutes 60 minutes
Which location(s)?
Buffalo / Office Snyder Lockport Clarence Center Larkin West Seneca
415 Elmwood Avenue Amherst Community Church First Presb. Church Epiphany UCC Larkin at Exchange Ebenezer UCC
Monday - Saturday 77 Washington Highway 21 Church Street 9365 Clarence Ctr.Rd. 726 Exchange St. 630 Main St.
Mon, Tues, Wed Monday Monday - Friday Monday -Friday Monday – Friday
When are you available for lessons? Circle all that apply. M T W TH F SA a.m. afternoon p.m.
Teacher preference, if known ______How many years of previous study have you had? ____ At CMS Other _____
What type of previous study? ______When? ______
Please list any medical conditions that may affect study ______
CLASSESENSEMBLES
(See catalog for details.) Full tuition is due with application. 25% discount for each additionalhousehold member.
Music, My Grownup & Me (ages birth-5)with Sean Crawford and Sarah Oguich
Monday10:30 amCrawfordElmwood4/9-6/18 Cost $200
Monday4:30 pmOguichElmwood4/9-6/18 Cost $200
Monday NEW!5:30 pmOguichElmwood 4/9-6/18 Cost $200
Thursday10:30 amCrawfordElmwood 4/12-6/14Cost $200
Friday10:30 amCrawfordElmwood 4/13-6/15Cost $200
Music & Me: On My Own (ages 3-5)with Maria Goodrich
Thursday3:30 pmElmwood 4/12-6/14Cost $200
Piano Exploration (ages 5-6)with Christina Brown and Anna Whistler(PE I – new students, PE II – returning students)
Monday6:30 pmWhistlerPE IElmwood 4/9-6/18 Cost $200
Tuesday5:15 pmBrownPE IIElmwood 4/10-6/12Cost $200
Instrument Exploration: Peter & The Wolf!(ages 4-7) with Sean Crawford
Friday3:45p.m.Elmwood 4/20-6/8Cost $160
The Joy of Singing Together (ages 6-9)with Maria Goodrich
Monday4:30 p.m.Elmwood 4/9-5/14 Cost $120
Ukulele 101: Just for Kids! (ages 5-10)with Brianna Nilsen
Wednesday4:30 p.m.Elmwood 4/11-6/13Cost $200
NEW! Kids Create! (ages 5-10) with CMS, Locust Street Art and Story Time Bookshop
Monday3:45 p.m.Elmwood& Locust St. 4/23-6/18 Cost $200
NEW! High School Piano Prep (sophomores, juniors & seniors)with Hassan Al-Mufti
Wednesday5:45p.m.Elmwood 4/11-6/13Cost $200
Introductory Piano for Adults with Hassan Al-Mufti
Wednesday11:00 a.m.Elmwood 4/11-6/13Cost $200
Wednesday5:00 p.m.Elmwood 4/11-6/13Cost $200
Fiddle ‘n Folk (teens & adults)with Phil Banaszak
Wednesday7:30 p.m.Elmwood 4/11-6/13Cost $130
Glee Club (teens & adults)with Maria Goodrich
Thursday6:30 p.m.Elmwood 4/12-5/17Cost $78
NEW! CMS Community Chorus (ages 16+)with Paul Waara
Tuesday7:00 p.m.Elmwood 3/13-6/12 FREE*
CAMP CREATE! (ages 5-10)with CMS, Locust Street Art and Story Time Bookshop
Session 19:30 p.m.Elmwood 7/16-7/20Cost $200
Session 29:30 p.m.Elmwood 8/13-8/17Cost $200
Session 1 + 29:30 p.m.------Cost $350
*$20 Registration fee for non-CMS lesson students