Community Music School
SUMMER 2017 Registration Form
Please complete both sides, sign below, and attach the registration/class/ensemble fee.

E-MAIL ______How did you hear about CMS? ______

1.) Last Name______First Name ______MI ____

Date of Birth ______Age ______ Male  Female School ______

2.) Last Name ______First Name ______MI ____

Date of Birth ______Age ______ Male  Female School ______

3.) Last Name ______First Name ______MI ____

Date of Birth ______Age ______ Male  Female School ______

Home Phone ______Cell Phone ______

Home Address ______City ______Zip ______

For Non-Adult Students

Parent’s(Guardian’s) Name ______

Address and Phone (if different from student’s) ______

Occupation ______Employer ______

Work Phone ______May we call you at work?  yes  no

Parent’s (Guardian’s) Name ______

Address and Phone (if different from student’s) ______

Occupation ______Employer ______

Work Phone ______May we call you at work? yes  no

Emergency Contact ______Phone ______

For Adult Students

Occupation ______Employer or School ______

Work Phone ______May we call you at work? yes  no

I have read and agree to abide by the CMS Policies and Procedures.

Unless advised otherwise in writing, your signature gives CMS permission to photograph you or your child and to use the image(s) in our print materials, website and social media. .

X______

SIGNATURE of Student or Parent/Guardian (if student is under 18)Date

Billing information: (please print)

Send bills to: Mr.  Mrs.  Ms. ______

Address (if different from student’s) ______

Please attach the non-refundable annual registration fee of $20 for first family member, $33 for two and $41 for three +.

To charge your VISA or MasterCard for the registration fee or class/ensemble tuition, please complete the information below. If you’d like your monthly installment billed to this card, please initial here: ______

CARD # ______Expiration Date ______$ Amount ______

Cardholder’s Signature ______3- Digit CVV ______

Would you like to make a donation to CMS using your credit card?If so, please write amount on the appropriate line below.

Friends of CMS (to support general operating): $____ CMS Capital Campaign(to support our renovation project): $____ CMS Scholarship Fund:$____

To be considered for financial aid, please submit a Financial Assistance Form with proof of household income.

Beneficiary Statistics Required by Funding Sources

Information on this form is confidential. Statistics are reported only in aggregate/total.

Ethnic/Racial BackgroundGross Family Income

 1) Caucasian 2) Black/African-American 1) Below $9,999 2) $10,000 – 19,999

 3) Latino/Hispanic 4) Asian 3) $20,000 – 29,999 4 $30,000 – 39,999

 5) Native American 6) Arab 5) $40,000 – 49,999 6) $50,000 +

 7) Other (or mixed): What ?______

Community Music School admits students of any race, color, gender, national or ethnic origin, sexual orientation and religious belief to all the rights, privileges, programs and activities generally accorded or made available to students at the School. It does not discriminate on the basis of race, color, gender, national or ethnic origin, sexual orientation or religious belief in the administration of its educational policies, admissions policies, scholarship programs and other school-administered program. CMS is proud to be a member of the National Guild for Community Arts Education and the Greater Buffalo Cultural Alliance, and a donor-designated agency of United Way of Buffalo and Erie County.

415 Elmwood Avenue  Buffalo, New York 14222  Phone: (716) 884-4887 Fax: (716) 884-7529

Buffalo  Clarence  Larkin  Lockport  Snyder  West Seneca

PRIVATE LESSONS

2017-18 lessons may be scheduled now with Jennifer Guillow. Your monthly payment will be determined by the lesson day. Your firstpayment must be received at least 1 day before the first scheduled lesson.

What would you like to study (piano, voice, clarinet etc.)? ______

What length lesson? 30 minutes 45 minutes  60 minutes

Which location(s)?

 Buffalo / Office  Snyder  Lockport  Clarence Center  Larkin West Seneca

415 Elmwood Avenue Amherst Community Church First Presb. Church Epiphany UCC Larkin at Exchange Ebenezer UCC

Monday - Saturday 77 Washington Highway 21 Church Street 9365 Clarence Ctr.Rd. 726 Exchange St. 630 Main St.

Summer: Closed Sat Mon, Tues, Wed Monday Monday - Friday Monday -Friday Monday - Friday

When are you available for lessons? Circle all that apply. M T W TH F SA a.m. afternoon p.m.

Teacher preference, if known ______How many years of previous study have you had? ____ At CMS  Other _____

What type of previous study? ______When? ______

Please list any medical conditions that may affect study ______

CLASSESENSEMBLES(See catalog for details.) Full tuition is due with application.

Music, My Grownup & Me (ages birth-4)with Sean Crawford (please circle time if multiple given)

Monday10:30 a.m.OR 4:30 p.m.Elmwood7/10-8/28Cost $140 for 7 classes

TuesdayNEW!10:30 a.m.West Seneca7/11-8/29Cost $120 for 6 classes

Tuesday6:30 p.m.Elmwood 7/11-8/29Cost $140 for 7 classes

Wednesday9:30 a.m.Elmwood 7/12-8/30Cost $120 for 6 classes

Thursday10:30 a.m.OR 3:30 p.m.Elmwood 7/13-8/31Cost $120 for 6 classes

 Friday10:30 a.m.Elmwood 7/7-8/25Cost $120 for 6 classes

Music & Me: On My Own (ages 3-5)with Maria Goodrich

Thursday3:30 p.m.Elmwood 7/13-8/31Cost $120 for 6 classes

Piano Exploration (ages 5-6)with Christina Brown

 Monday3:30 p.m.Elmwood 7/17-8/14Cost $100 for 5 classes PE1

 Monday4:30 p.m.Elmwood 7/17-8/14Cost $100 for 5 classes PE1

Monday5:30 p.m.Elmwood 7/17-8/14Cost $100 for 5 classes PE2

Instrument Exploration (ages 5-8) with Sean Crawford

Friday11:30 a.m.Elmwood 7/7-8/25Cost $120 for 6 classes

The Joy of Singing Together (ages 6-9)with Maria Goodrich

Monday4:30 p.m.Elmwood 7/10-8/28Cost $140 for 7 classes

Ukelele 101: Just for Kids!with Sara Rogers

 Wednesday6:00 p.m.Elmwood 7/12-8/30Cost $80 for 8 sessions

NEW! Electronic Strings (teens & adults) with Evan Courtin

Monday7:00 p.m.Elmwood 7/10-8/28Cost $160 for 8 classes

Introductory Piano for Adults with Hassan Al-Mufti

Tuesday5:15 p.m.Elmwood 7/11-8/22Cost $120 for 6 classes

Wednesday11:00 a.m.Elmwood 7/12-8/23Cost $120 for 6 classes

Ukulele 101: Teens & Adultswith Sara Rogers

 Wednesday 6:45 p.m.Elmwood 7/12-8/30Cost $80 for 8 sessions

Fiddle ‘n Folk (teens & adults)with Phil Banaszak

Wednesday7:00 p.m.Elmwood TBDCost $60 for 6 sessions

Glee Club (teens & adults)with Maria Goodrich

Thursday6:00 p.m.Elmwood 7/13-8/31Cost $60 for6 sessions

NEW! Camp Create! (ages 5-10)

Weekdays9:30 a.m.Elmwood 7/17-7/21Cost $175

NEW! Summer Stringswith Evan Courtin

Tuesday11:00 a.m.Elmwood 7/11-8/22Cost $150

NEW! Summertime Rocks! (ages 10+)with Kevin Helfrich and Gary Rutkowski

Wednesday6:00 p.m.Elmwood 7/12-8/23Cost $60 for 6 sessions

NEW! Vocal Boot Camp (teens & adults)with Maria Goodrich and Paul Waara

Monday5:00 p.m.Elmwood 7/24-8/21Cost $150

NEW! Band Camp (adults)with Sean Crawford

Monday6:30 p.m.Elmwood 7/17-8/28Cost $60 for 6 sessions

NEW! Seniors Sing (adults)with Audrey Shafer

Wednesday11:00 a.m.Elmwood 7/12-8/23Cost $70 for 7 sessions