Student Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

(###)

###

####

Emergency Phone Contact

(###)

###

####

Parents/Guardians

First Name

Last Name

Parents/Guardians

First Name

Last Name

PHOTO WAIVER *

Occasionally. Rivertown Music prints and publishes promotional materials. Please select appropriately:

Yes, I grant Rivertown Music to use my photos and/or my child's photos.

No, I do not grant Rivertown Music to use my photos and/or my child's photos.