Student Contact Information
Goldberg School of Music Summer Program 2019

Please complete and submit all requested information no later than Friday, July 5, 2019. This information will be kept private and only for use as it is intended or needed: for personal contact, student safety and with your permission.

If you have questions, please contact Helena Goldberg at: thegoldbergschoolofmusic@gmail.com
Thank you!
Helena
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Email *
Student First Name *
Student Last Name *
What week(s) is your child attending? Please check all that apply. You can add specific dates in the next field. *
Required
Please specify what location/dates your child will attend each week if they are not attending everyday.
Parent/Guardian Name/Phone Number(s)/Email *
Parent/Guardian Name/Phone Number(s)/Email
Student Address *
Parent Address (if different from Student)
Emergency Contact Name(s) and Phone Number(s) other than Parent/Guardian:
Name/Phone Numbers of those authorized to transport student (other than parent/guardian) to and from camp:
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