Music Therapy

@ Carmel High School (C-3 Partnership)

Student's Name*
First Last
Student's Birthdate*
Month
Day
Year
Parent/Caregiver's Name*
First Last
Address*
Street Address Address Line 2 City State Zip code
Email*
Phone*
Photo & Video Release*
Photos and videos may be used for promotional purposes on our website, social media, and print materials. If you do not grant permission, photos and videos of your student will not be used outside of class for any reason.
Please list any special considerations
Please list any special needs, allergies, or other issues so that your student can be best served.
Complete your registration:*
- Pay in FULL ($200.00)
Payment Method

MasterCard
Visa
Supported Credit Cards: MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name