RockonAmerica
Fill out this form and click "submit" at bottom of page. We will contact you within 24 hours with info on group times and starting dates that match your profile!
Email Address
Name:
Age:
Grade:
If under 18, parent's email address
Date
Address
City, State
Zip
Tel.
Cell# & Emergency #
Check which level you're interested in. Level 1 (No previous playing experience) Level 2 (Have had some lessons or self taught)
Level 1
Level 2
If you already have some playing experience, for how long and on what instrument? If "no experience" what instrument would you like to try?
No experience
Describe..
Check which styles of music you like!
Rock
Pop
Blues
Punk
Classic Rock
Fusion
Ska
Jazz
Funk
Metal
Other
Name 3 songs you might like to do with your group.
I sing...
A little
A lot
No way
I make up my own music..
Yes
No
Would like to!
I have friends that I want to be with me in this group.
Yes
No
If YES what are their names?
Best day(s) for me to Rock are (check as many as possible)...
Mon
Tues
Wed
Thu
Fri
Sat
Sun
12pm-4pm
4pm-8pm
Where did you hear about RockonAmerica?
Friend
Print Ad
TV
Radio
Bethel Music Ctr rep.
Poster-flyer
Website
Other
If under 18 please have your parent confirm this information by email to RockonAmerica@optonline.net
If under 18 do you have your parent's permission to enroll in this program?
yes:)
no:(
I understand that this program is not free! (However there is no fee to register here)!
Yes
No
Any questions? Thank you!
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