Online Application – Mountain Music School

Registration is open for the 2024 Mountain Music School
Payments can be mailed to: Workforce Solutions 3441 Mountain Empire Rd, Big Stone Gap, VA 24219
Attn: Lori Dingus
Date:*
MM slash DD slash YYYY
Name*
First Name Last Name
Address*
Street Address Address Line 2 City State ZIP Code
Phone:*
Email
Age of Participant (All youth participants must be ages 10-17):*
Participant Date of Birth*
MM slash DD slash YYYY
Diet Restrictions (Please list any specific diet restrictions):*
- None
Class Preference - Choose one only (experience means weekly practice):*
Loaner Instruments - $25 DEPOSIT REQUIRED IN ADDITION TO REGISTRATION FEE
I wish to apply for a "Loaner" instrument to use for the week and understand that I will be financially responsible for any damage to the instrument or not returning instrument:*
T-Shirt Size - Choose one only:*
Please note, the registration fee MUST be paid by July 10th.
Registration Fees*
- Students 10 - 17 years of age: $50.00 per student (ADD $25 FOR ANY LOANER INSTRUMENT REQUESTS)
- Students 18 and older - $150.00 per student (ADD $25 FOR ANY LOANER INSTRUMENT REQUESTS)
Parent(s) for students 10-17, please enter your name below (adult participants please specify N/A):*
Parent(s) for students 10-17, please enter your driver's license number below (adult participants please specify N/A):*
Parent's address, if different from student (or specify N/A):*
Parent's telephone number for emergency (or specify N/A):*
Consent
I agree to the privacy policy.