Marlene Sampaio's Music Studio
Summer 2017 Registration Form
For Theory, Harmony, History & Private Instruction
Student Name______________________________________ Birthdate ___________________________________
(dd/mm/yy)
Parent/Guardian Name: _______________________________________________________________________
Street: _____________________________________________________________________________
City: ____________________________________________ Postal Code: ___________________________
Primary Phone Secondary Phone
☐Cell ☐Home ☐Business:_____________________ ☐Cell ☐Home ☐Business: ____________________
Email: __________________________________________________________________________________________
☐Check here if we are not to use this address to send you studio information and updates
I would like to register for:
☐ Theory (formerly Rudiments)
Primary Instrument ________________________
Level ____________________________________
☐ History Level ________________________________
☐ Harmony Level ______________________________
☐ Private Instruction (piano only)
Level ______________________________________
Amount enclosed $ _______________________ please make all cheques payable to Marlene Sampaio.
Note: Applicants for the Royal Conservatory of Music (RCM) exams are due on June 1, 2017. For more information visit www.examinations.rcmusic.ca. If the student intends to write the exam at the the end of this course in August, it is their responsibility to ensure they are registered with the RCM on time.
