Applicant Name *

First Name

Last Name

Primary Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Female

Male

Other

Date of Birth

MM

DD

YYYY

Primary Instrument *

flute

clarinet

oboe

bassoon

saxophone

trumpet

trombone

tuba

euphonium

french horn

piano

How did you first learn about the Seven Pillars Music Academy *

Teacher

Friend

Advertisement/Magazine

Facebook

Internet Search

Academy Brochure

Email Announcement

Poster

Other

Parent/Guardian Name

First Name

Last Name

Primary Phone

(###)

###

####

Primary Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Begin Date

MM

DD

YYYY

Date of Completion

MM

DD

YYYY

Instructor's Phone Number

(###)

###

####

*

I have read and understand the application process.

*

I have read and understand the payment process.

*

I have read and understand the cancellation terms and conditions.

*

I have read and understand the Seven Pillars risk and liability statement.

*

I have read and understand the Seven Pillars privacy statement.

I hereby authorize Seven Pillars to use my photo, and/or information related to my experiences with the Seven Pillars Music Academy. I understand this information may be used in publications, including electronic publications, audio/ visual presentations, promotional literature, advertising community presentations, letters to area legislators and media and/or other similar ways. *

YES

NO

My consent is freely given as a public service to Seven Pillars, without expecting payment. I release Seven Pillars and their respective employees, offers and agents from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, videotape and/or photographs. *

YES

NO

Once accepted, I consent to all photography and videos taken throughout the event. *

YES

NO

I prefer that *

my complete name be used

my first name only be used

no name be used

no preference

Applicant Signature *

First Name

Last Name

Signature Date *

MM

DD

YYYY

Parent/ Guardian Signature

First Name

Last Name

Parent'Guardian Signature Date

MM

DD

YYYY