Register #8791 - vancomusic

Registration Form

I am a:

Parent / Guardian

Student Information

First name:

Anisa

Last name:

Daneshi

Date of Birth:

2014-05-12

Parent Information

First name:

Zohreh

Last name:

Jamali

Parent / Guardian's Email:

zohreh_jamali77@yahoo.com

Contact Number:

6043888085

Relationship to student:

Mother

Address

Country:

Canada

City:

Coquitlam

State / Province / Region:

BC

Address Line 1:

2208 - 3080 Lincoln Avenue

Address Line 2:

ZIP / Postal Code:

V3B 0L9

Program Selection

I am looking for:

In-person Lessons

What level would you like to register?

Level 5-8

Please write the program or instrument you are interested in:

Violin

How many days a week would you like to have classes?

Once a week

Which days are you available for lessons?

Fridays

We'd love to know how you heard about us:

Referral

Referrer: