Music with Amy House
4417 Morrowick Road, Charlotte, NC  28226
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Registration

Please use the following form to register your child for one of our classes.  Upon  receipt of this registration, you will be contacted by Amy House to confirm your registration and answer any questions you may have.

Select Class:  
Preferred Day/Time: 
Parent's First Name:  
Parent's Last Name:  
Address Line 1:  
Address Line 2:  
City:  
State/Province:           Zip/Postal Code:  
Email Address:  
Home Phone Number:   -   -  
Work Phone Number:   -   -  
Cell Phone Number:   -   -  
Alternate Contact Person:  
Alt. Contact Phone:   -   -  
Child's First Name:  
Child's Last Name:  
Child's Current Age:   months     years
Child's Birthdate:   (MM/DD/YYYY)  
List any allergies or medical
issues of which the teacher
should be aware:  
How did you hear about us?:
Other:
Question/Comment:  
 
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