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					               Dave Simon’s Rock School Sign Up Form

Today’s Date:
Students Last Name:

Students First Name:

Parent(s) Name:

Students date of birth:

School:
Grade:

Instrument(s) your child plays:
Years or months playing instrument(s):

Home phone:
Work phone:
Cell phone:

Mailing address(including zip code):

Email (student):

Email (parent):

Would you like to receive your billing invoice via email?

How did you hear about Rock School?

Is your child currently taking private lessons?

Please check all available time slots
                        3:00      3:30          4:00      4:30     5:00    5:30      6:00       6:30    7:00      7:30
       Monday
       Tuesday
       Wednesday
       Thursday
       Friday
                     10:00     10:30    11:00     11:30    12:00   12:30   1:00   1:30   2:00   2:30   3:30    4:00   4:30

       Saturday

By signing this document I, (name)______________________________grant Dave Simon’s Rock School permission to use either a
photograph, video or film image of my child for the promotion of Rock School. Promotional materials include Dave Simon’s Rock
School web site, brochure, poster orNews related mediums.

(Signature)

                                 1305 Baur Blvd St. Louis MO 63132 314.692.7625
                                  dsrockschool@yahoo.com www.dsrockschool.com

				
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