Your Favorite Melodies — Now and Then Application

First name

Last name

Date of Birth

Age Group

Email

Phone Number

Address Line 1

Address Line 2 (leave blank if not applicable)

City

State/Province

Zip/Postal code

Country

Instrument

Music Information

Full title of piece

Composer

Length in minutes and seconds (Do not guess)

Instructor Information

First name of instructor

Last name of instructor

Instructor email

Instructor phone

***Make sure to confirm payment before submission

Payment

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**A 5% Convenience Fee should be included in the online payment