Winter 2019 EMU Community Music Academy Early Childhood Music Class Registration
Classes begin on Monday, January 28 OR Saturday, February 2.
Email address *
Instructions:
Registering is a two-step process:

1) Select the course for which you wish to register from the list below and complete the remainder of the form. (Please submit separate forms for each student.)

2) If registering on or before January 21, please mail your payment to the following address:
EMU Community Music Academy, c/o Dr. Heather Shouldice
N101 Alexander Music Building
Eastern Michigan University
Ypsilanti, MI 48197
If registering after January 21, please bring payment to your first class.

**PLEASE NOTE: We are no longer able to accept cash. Please pay by check made payable to Eastern Michigan University.

Registration is not complete until payment has been received.

Which class would you like to register for? *
Do you qualify for any of our discounts?
Student Name (first & last) *
Your answer
Student Birthdate *
Your answer
History of musical experiences:
Your answer
Musical goals:
Your answer
Does the student have any special circumstances of which the EMU CMA staff should be made aware?
Your answer
CONTACT INFORMATION FOR PARENTS/GUARDIANS
Parent/Guardian 1 Name (first & last)
Your answer
Parent/Guardian 1 Email Address *
Your answer
Parent/Guardian 1 Mailing Address (street, city, state, zip)
Your answer
Parent/Guardian 1 Phone Number
Your answer
Parent/Guardian 1 Alternate Phone (if applicable)
Your answer
Parent/Guardian 2 Name (first & last)
Your answer
Parent/Guardian 2 Email Address
Your answer
Parent/Guardian 2 Phone
Your answer
Referral Information: How did you hear about us?
Your answer
A copy of your responses will be emailed to the address you provided.
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