Course Name

Course Fee

Please enter the Parent/Carer/Contact details below

Parent/Carer/Contact First Name

Parent/Carer/Contact Last Name

Parent/Carer/Contact email address

Emergency Mobile No

Alternative Emergency No

Home Phone No

Street Address e.g. 99 Crispin Drive

Street Address e.g. Woodlands Park

Postal Town e.g. Bedford

County e.g. Bedfordshire

Post Code e.g. MK44 1JR

Please enter the Student details below

Student First Name

Student Last Name

Student SexSelect SexMaleFemale

Email address

Mobile No

Which group are you already in, if any?Select GroupNoneSymphony OrchestraString OrchestraSymphony BrassWind BandChamber CourseConcert OrchestraTraining BandYouth ChoirYouth Opera

Instrument e.g. Tuba

Standard (Grade equivalent)Select GradeNone12345678

AgeSelect Age891011121314151617181920212223242526

Date of birth if using IE or Firefox browser format as YYYY-MM-DD

School / College

Instrumental Teacher

How did you hear about us?Select OptionCounty Music ServiceDirect MailMusic TeacherPressWeb SiteWord of MouthOther

Do you have any medical conditions?YN

Medical Condition Details

Any additional notes/comments?

Are you happy for your details to be shared regarding car sharing?YN

Do you agree to your student leaving the venue under their own responsibility during course days?YN

Are you happy for photographs/video being taken by BMT to be used solely for BMT marketing purposes?YN

Do you agree to receiving emails from us regarding this/future events?YN

I have read and accept the Terms & Conditions

Clicking on the following button will send the above details to Bedfordshire Music Trust and you will receive an acknowledgement email. In addition you will be redirected to your shopping cart where you can pay on-line using PayPal or you may add another student booking.

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