Student Name *

First Name

Last Name

Primary Contact Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Address

(if different from student)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Phone

(###)

###

####

Photo Release Agreement *

I am the parent or legal guardian of the listed child registrant who is under 18 years of age, and as noted above I hereby give permission for photographs or video of the child being registered to be published on the website of the Oshkosh Suzuki Music Program or used for other purposes related to the Oshkosh Suzuki Music Program such as media advertising and brochures.

Yes

No