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Suzuki - concertsplus (Page 3)

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Suzuki - concertsplus
Concerts Plus Registration Form
Closing Date Friday 8 September.
Please return this form with full payment to Suzuki Music before Friday 8 September.
Applications and payments received after this date will incur a late fee of $7.50 per family.
Parent Name _____________________________ Memb No _______ Phone ________________________
CHILD 1
Name __________________________________________ Date of Birth _________________
Concert Time
(see program)
____________ Enrichment Activity Time
(see program)
____________
Piano Teacher to complete:
(Please note that pieces must be at concert standard)
Concert Piece Book ______Title
(incl Movement)
_________________________________________________
Composer _____________________________________________________ Duration __________________
Teacher Name ________________________________ Teacher Signature _________________________
PAYMENT DETAILS
Cost $30 one child, $45 two children, $55 three children
(Late Fee $7.50 per family must be added for all registrations received after Friday 8 October)
Total Amount $ _____________
Cheque/Money Order Credit Card* (Bankcard / Mastercard / Visa)
(
* Credit card transactions will incur an additional 2% surcharge
Card No
_ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
Expiry
Date
_ _ / _ _
Cardholder's Name ________________________________ Signature _____________________________
SUZUKI MUSIC
PO Box 439 Kew East VIC 3102
((03) 9859 0433 Fax (03) 9859 0477 Email: info@suzukimusic.org.au
Suzuki Talent Education Association of Australia (Vic.) Inc. Reg. No. A5744; ABN 14 080 413 955
CHILD 2
Name __________________________________________ Date of Birth _________________
Concert Time
(see program)
____________ Enrichment Activity Time
(see program)
____________
Piano Teacher to complete:
(Please note that pieces must be at concert standard)
Concert Piece Book ______Title
(incl Movement)
_________________________________________________
Composer _____________________________________________________ Duration __________________
Teacher Name ________________________________ Teacher Signature _________________________
CHILD 3
Name __________________________________________ Date of Birth _________________
Concert Time
(see program)
____________ Enrichment Activity Time
(see program)
____________
Piano Teacher to complete:
(Please note that pieces must be at concert standard)
Concert Piece Book ______Title
(incl Movement)
_________________________________________________
Composer _____________________________________________________ Duration __________________
Teacher Name ________________________________ Teacher Signature _________________________

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