Summer of Rock 7

Rocker’s Name: ________________________________________________________________________________________

 

Email: ___________________________________          Age: _____________

 

Phone: _____________________          Cell:__________________________

 

Address: _______________________________________________________________________________________________

 

_______________________________________________________________________________________________________

 

Parents/Guardians ____________________________________________________________________________________

 

Email: ________________________________________________________________________________________________

 

Phone: _____________________        Cell: ___________________________

 

Address (if different from above): _______________________________________________________________________

 

_______________________________________________________________________________________________________

 

 

Medicare #: ___________________________________________________________________________________________

 

Allergies or Concerns: _________________________________________________________________________________

 

________________________________________________________________________________________________________

 

I currently play: ________________________________________________________________________________________

 

I would like to learn/improve upon: _____________________________________________________________________

 $300.00 payment will be made by    Cheque __   Cash __   Credit Card __

Let’s ROCK !!