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*Matthew's House at First Presbyterian Church, 531 S College Avenue, Fort Collins, CO 80524Academy of Arts and Knowledge, 4800 Wheaton, Dr, Fort Collins, CO 80525Boys and Girls Club Fort Collins, 1608 Lancer Drive, Fort Collins, CO 80521Boys and Girls Club Loveland-Pulliam, 2500 E. 1st Street, Loveland, CO 80537Private Music Lesson Program ParticipantIn 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?*ViolinGuitarPianoProductionOther (type below)Fill only if selected "other" above Name of Parent/Guardian 1* First Last Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Name of Parent/Guardian 2 (optional) First Last Phone2nd Address (optional) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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* Δ