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Summer 2012 Catalog - Peabody Institute - Johns Hopkins University

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PEABODY PREPARATORY SUMMER <strong>2012</strong> REGISTRATION FORM<br />

Student Information<br />

◦ I am a new student to the Preparatory<br />

◦ Male<br />

◦ I am a continuing student<br />

◦ Female<br />

Student Name <br />

Birth Date / / (required for ISIS ID) Ethnicity <br />

Account Billing Information (Parent or Guardian if student is under 18) ◦ Mr. ◦ Mrs. ◦ Ms. ◦ Miss ◦ Dr. ◦ Prof.<br />

Name Birth Date / / (required for ISIS)<br />

Address<br />

SS# <br />

City State Zip <br />

Phone (Please circle preferred method of contacting you)<br />

Home<br />

Cell<br />

Work <br />

Email <br />

Emergency Contact (Please circle preferred contact method)<br />

Name<br />

Relationship <br />

Daytime Phone Email <br />

Individual Instruction (Independent Study)<br />

If you are new to an instrument please write “needed” in the teacher field. Leave the day and time fields blank. Once we receive your form<br />

with full payment, we will contact you to arrange placement with a teacher.<br />

Instrument One Course Code Teacher <br />

Lesson Length: (Circle One) 30 minutes ($270.00) 45 minutes ($405.00) 60 minutes ($540.00)<br />

Day: Time Campus <br />

Instrument Two Course Code Teacher <br />

Lesson Length: (Circle One) 30 minutes ($270.00) 45 minutes ($405.00) 60 minutes ($540.00)<br />

Day: Time Campus <br />

UNLESS NOTED PHOTOS BY WILL KIRK<br />

Group Classes<br />

If you are a new dance student, you must contact the Dance Dept. for placement at 410-234-4626, prior to registering. If registering for<br />

camps, either register online at the camp’s webpage or complete the specific application form (see camp description for details).<br />

Course # Name $ <br />

Course # Name $ <br />

Course # Name $ <br />

Total Individual Instruction Tuition<br />

Total Group Class Instruction Tuition<br />

$ <br />

$ <br />

Carry this total to the payment calculation on the back page: Total Tuition Due $

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