SUMMER MUSIC CAMP - DFW Music Academy

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Student's Name *

First

Last

Cell Phone *

Student's Email *

Confirm Email

Parent's Email *

Confirm Email

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Birthdate *

Sex *

Male
Female

Summer Camp Dates *

June 17th - 20th
July 15th - 18th

Parent Information

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Parent 1 Name *

First

Last

Parent Cell Phone *

Parent 2 Name

First

Last

Parent 2 Cell Phone

Emergency Information

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Emergency Contact Name *

First

Last

Phone *

Medical Information that DFWMA staff and instructors need to know: *

Billing Address information

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Debit/Credit Card Authorization – Debit/Credit Card Payments –

*All Debit Cards will process as a credit card*

I authorize DFW Music Academy to perform debits and/or credits for the summer camp of $250 per camp.

Card Type *

Visa
MasterCard

Card # *

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Exp *

CVC *

Zip *

Today's Date *

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