Recital Registration Form

Student's Name *

Parent/Guardian's Name (if student is under 18 years of age)

Address 1 *

City *

State *

Zip Code *

Phone Number *

Email Address *

Recital Date and Time *

Instrument *

Select Teacher *

In checking this box, I (parent/guardian or adult student) give permission to Central Penn Music to use media from the recital in print or electronic promotions. Central Penn Music will not publish the names of students without parental consent. *

Yes, I give my permission

No, I DO NOT give my permission

Central Penn Music Recital Information

We are very excited to be able to offer our students the opportunity to participate in a recital! The recitals are currently being held at the Londonderry Village retirement community in their chapel. The address is:

8 Kettering Ct., Palmyra PA 17078.

1 .Because of space limitations, we need to limit the number of participants. Selection will be made in the order we receive your registration.

2. A fee of $20 will be required to help offset the expenses associated with the recital including the time your instructor will spend the day of the recital.

3. Please complete this form by April 20 at the latest. Payment must be made at time of submission. There is a box to select using the payment method currently on file for your lessons.

4. It will be required that lesson fees for the month of May have been paid to participate in the recital.

5. Audience seating is by general admission and cannot be reserved ahead of time.

6. Pariticipants should arrive no later than 2:30 for the recital.

7. Central Penn Music reserves the right to cancel a recital day/time if it does not have a full schedule of participants. In this case, all students will be notified and moved to a different time/day or the fee will be credited toward the next lesson payment.

I have read & agree to the recital guidelines *

Yes

Name on Card

Credit Card Type (Card on File is an option) *

Credit Card Number

CVV

Expiration Date (mm/yy)

I hereby authorize Central Penn Music to charge my credit card for the one time recital fee of $20. If submitted electronically your typed signature will count the some as a written signature.

Sign here *

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Today's Date * +