MUSIC CLASSES REGISTRATION FORM - Mohamed Assani
MUSIC CLASSES REGISTRATION FORM - Mohamed Assani
MUSIC CLASSES REGISTRATION FORM - Mohamed Assani
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PERSONAL IN<strong>FORM</strong>ATION:<br />
Unit 114 - 12827 76th Avenue, Surrey, BC, V3W 2V3<br />
Tel: 604.767.3564 | Email: info@southasianarts.ca<br />
Web: www.southasianarts.ca<br />
<strong>MUSIC</strong> <strong>CLASSES</strong> <strong>REGISTRATION</strong> <strong>FORM</strong><br />
Participant Name: ________________________________________ Gender: M / F<br />
Date Of Birth (mm/dd/yyyy): ___/___/______ Grade: ________ T-shirt Size: XS / S / M / L / XL<br />
Street Address: __________________________________________ City & Province: ____________________<br />
Postal Code: _______________ Home Phone: _____________________ Cell: _______________________<br />
Email: ____________________________________________________________________________________<br />
Mother’s Full Name: ____________________________ Father’s Full Name: ___________________________<br />
(if participant is under 18) (if participant is under 18)<br />
Emergency Contact Name:____________________________ Emergency Contact Phone #: _______________<br />
Would you like to be added to South Asian Arts’<br />
mailing list to get emails about upcoming events?<br />
Would you like to be added to the instructor’s<br />
mailing list to get emails about upcoming his<br />
events? (if available)<br />
CLASS IN<strong>FORM</strong>ATION<br />
Which class would you like to enrol in? (please tick):<br />
Youth Sitar:<br />
Instructor: <strong>Mohamed</strong> <strong>Assani</strong><br />
(8-17 yrs)<br />
Wednesdays, 4:30 PM – 5:20 PM<br />
Youth Tabla:<br />
Instructor: <strong>Mohamed</strong> <strong>Assani</strong><br />
(8-17 yrs)<br />
Wednesdays, 5:30 PM – 6:20 PM<br />
Adult Sitar<br />
Instructor: <strong>Mohamed</strong> <strong>Assani</strong><br />
(18+)<br />
Wednesdays, 6:30 PM – 7:20 PM<br />
Adult Tabla:<br />
Instructor: <strong>Mohamed</strong> <strong>Assani</strong><br />
(18+)<br />
Wednesdays, 7:30 PM – 8:20 PM<br />
Beginner Dhol: Instructor: Gurpreet Sian<br />
Mondays, 6:00 PM – 7:00 PM<br />
Intermediate Dhol: Instructor: Gurpreet Sian<br />
Mondays, 7:00 PM – 8:00 PM<br />
Yes / No<br />
Yes / No<br />
Has the participant previously received any musical training? Yes / No<br />
If yes, name of faculty: ________________________ Attendance from: ___________ to: ___________<br />
Were there any problems or anything that you would like us to be aware of? Yes / No<br />
If yes, please describe: _________________________________________________________________<br />
Do you have your own instrument for the class? Yes / No<br />
(If not, we have instruments available for rent)
PAYMENT IN<strong>FORM</strong>ATION<br />
Unit 114 - 12827 76th Avenue, Surrey, BC, V3W 2V3<br />
Tel: 604.767.3564 | Email: info@southasianarts.ca<br />
Web: www.southasianarts.ca<br />
Autumn Semester (September 14, 2011 – December 7, 2011. Total: 13 classes.)<br />
___ $235 for the first participant<br />
___ $210 for every additional participant in the same household OR if registered by August 15 th , 2011<br />
Winter Session (January 11, 2012 – April 18, 2012. Total: 13 classes.)<br />
___ $235 for the first participant<br />
___ $210 for every additional participant in the same household OR if registered by August 15 th , 2011<br />
Spring Session (May 1, 2012 – June 27 2012. Total: 9 classes.)<br />
___ $165 for the first participant<br />
___ $150 for every additional participant in the same household OR if registered by August 15 th , 2011<br />
Full Year (September 2011 – June 2012. Total: 35 classes.)<br />
___ $570 for the first participant if registered by August 15 th , 2011<br />
___ $635 for every additional participant in the same household OR if registered by August 15 th , 2011<br />
Payment may be made by cash or cheques made payable to South Asian Arts.<br />
MEDICAL IN<strong>FORM</strong>ATION:<br />
Please state if the participant has any allergies to medications, chronic illnesses, breathing/heart problems, or<br />
any other conditions that may deem important information in the case of an emergency.<br />
_________________________________________________________________________________________<br />
Is the participant on any medication at this time? (Yes / No) If yes, please specify.<br />
_________________________________________________________________________________________<br />
Doctors Name: ____________________________________________________________________________<br />
Doctors Telephone #: ____________________________ Healthcare #: ______________________________<br />
By signing below you agree to the following conditions:<br />
1. You authorize us to provide music training services.<br />
2. You understand that we do not guarantee results and that results may vary from participant to participant.<br />
3. You agree to stay home if you have any communicable diseases or infections.<br />
4. It is the policy of South Asian Arts to notify a parent or emergency contact when a participant is ill or needs<br />
medical attention. Occasionally we cannot contact the parents or emergency contact and we need to get<br />
immediate help for the participant by taking them to the nearest emergency service. By signing below, you give<br />
your consent to South Asian Arts to take appropriate action on behalf of the participant.<br />
5. You understand that in case of injury, all claims against the centre in excess of public liability insurance carried by<br />
the centre are hereby waived.<br />
6. You have read and fully understand all the terms and conditions.<br />
I have enclosed my tuition fee of $___________________.<br />
________________________________________<br />
Participant / Parent Signature<br />
(For participants under age 18, the signatory represents<br />
to South Asian Arts that they are the sole legal custodian<br />
of the participant and that they have the authority to enter<br />
into the above agreement on the participant’s behalf.)<br />
__________________________<br />
Date Signed<br />
Please return this completed form and payment (cheque<br />
or cash) to: South Asian Arts<br />
114 – 12827 76 th Avenue, Surrey, BC, V3W 2V3<br />
Please do not send cash by post
Unit 114 - 12827 76th Avenue, Surrey, BC, V3W 2V3<br />
Tel: 604.767.3564 | Email: info@southasianarts.ca<br />
Web: www.southasianarts.ca
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