Meadowlark Registration Form

Note: This program is open for 1st through 5th grade students only.

Are you a returning participant?*
- Yes
- No
Student(s) Name(s)*
Student(s) Age(s)*
Location*
In order to register for Meadowlark Music Program lessons, students must be enrolled or involved in programming at the Boys and Girls Club, Matthews House programming, or the Academy of Arts and Knowledge. Other lessons can be arranged. Please contact Jephta Bernstein, Executive Director, for more information: director@box2039.temp.domains.
Instrument you would like to learn?*
Fill only if selected "other" above
Name of Parent/Guardian 1*
First Last
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Name of Parent/Guardian 2 (optional)
First Last
Phone
2nd Address (optional)
Street Address Address Line 2 City State ZIP Code
Email
We invite participants to “pass it on” by putting any dollar amount into the lesson fund should you ever be in a position to do so. All information will remain confidential. If you have questions, please contact us by phone at 970-305-2261 or email: director@box2039.temp.domains. If you would like to make a donation, please click here.
Electronic Signature*

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