Student Registration Form
Community Through Creativity
Student First Name *
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Student Last Name *
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Date of Birth (if under 18 yrs of age)
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Address
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City
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State
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Zip
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School Name
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Grade
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Years of Experience
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Primary Contact Name (Student or Parent/Guardian if under 18 yrs of age) *
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Primary Contact Cell Phone # *
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Primary Contact Home/Other Phone #
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Primary Contact Email *
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Primary Contact Preferred Contact Time
Secondary Contact Name
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Secondary Contact Cell Phone #
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Secondary Contact Preferred Contact Time
Secondary Contact Email
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Other Phone # (Please Specify)
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Emergency Contact Name
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Emergency Contact Phone #
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Other Information (Known allergies, disabilities, etc.)
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How did you hear about Soltani Music?
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