Student's Name:

Age: (if under 18)

Sex: Male aaaa Female

School:

Grade:

Clarinet (Bb, alto, bass, other) :

Years of study on clarinet:

Private Instructor:

Band Director:

Parent/Guardian:

Mailing Address (street, city, zip):

Primary Phone:

Alternate Phone:

Email:

REGISTRATION:

I would like to register for the Clarinet Clinic, including room and board at Stetson University: $395

I would like to register for the Clarinet Clinic, including lunch and dinner at Stetson University (local students only): $295

I would like to purchase a t-shirt for $15

T-Shirt Size

S aaaa M aaaa L aaaaXL

If you have a room mate that you would like to be assigned, enter their name in the space provided:

Comments or Questions: