LCCMS Form

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Student Name*
Phone Number*
Email address*
Grade in school (if applicable)
Parent/Guardian Name(s)
I would like to register for the following class:
List Items*
If you're taking private lessons, please indicate your instrument(s) below:
I give permission to release photos and/or video of the child listed above for the program website, Facebook page, area news sources, and local media sources.*
I hereby release Luther College and its officers, agents, employees, and members of LutherCollege from all liability for damage and/or injuries that my child may sustain participating in and/or traveling to and from Luther College Community Music School events. I also understand that Luther College shall assume no responsibility or liability for my child for accidents or illness, and I acknowledge and do hereby assume all risks inherent in my child's participation in and/or transportation to this event. I hereby hold Luther College and its respective officers, employees,agents, and representatives harmless from any and all liabilities, actions, claims, and damages of any kind and nature whatsoever caused by or due to my child's participation in the Luther College Community Music School.
I am applying for financial assistance. Please send us the first page of your federal tax return. (LCCMS, Luther College, 700 College Drive, Decorah, IA 52101 OR scan and email to [email protected]).
Payment Amount*
$

Payment Information

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Billing Street Address*
City*
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Country*
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