Student Registration: 2007 - 2008

Student:
Address:
City:
State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:
Phone:
Date of Birth:		Age:
Parent (if applicable):

Registration Information:
Registration may be done in person, by mail, email, fax (909) 624-3502 or phone (909) 624-3012. Payments may be made with Mastercard, VISA, Discover, or check. There is a $20 registration fee for all students. The first tuition installment must be paid for registration to be accepted.

Private Instruction:
Before registering, new students must contact the office at (909) 624-3012 to make arrangements. Continuing students must make arrangements with their teacher prior to submitting this registration form.

Teacher Name:
Lesson Day & Time:
Approved by Teacher:	Yes   No
Lesson Length:
Number of Payments:	1   3   9
Tuition (per brochure):

Group Instruction:
Please refer to the course description in the brochure to complete the following:

Class Title:
Class date or session and time:
Number of Payments:	1   2   3   9

Tuition: (per brochure):
Materials fee (if applicable):
Registration $20 1st family member, $10 additional family member(s):
Supporting Donation
	Total Due:

I/We agree to hold CCSM, its staff, faculty and volunteers harmless in the event my child is injured while participating in CCSM activities:

I/We grant CCSM permission to make still pictures, videotapes, or sound recordings to use for marketing and/or communication purposes and the right to exhibit the recordings, prints and/or videotapes to any responsible individual, publication, TV station or governmental agency, or to any of their assignees:

Payment:
I am mailing a check to CCSM, P.O. Box 53, Claremont, CA 91711
I will charge my credit card through the on-line payment option (see next screen)