2017 SUMMER CAMP REGISTRATION FORM
Account Number:
(Each Student MUST Complete a Separate Form)
CONTACT INFORMATION
Family Last Name:
First:
Years of Study:
 Mr.
 Mrs.
Parent/Guardian:
 Miss
 Ms.
Instrument:
/
Street address:
/
Home phone:
P.O. box:
City:
Cell:
Province:
Email:
Teacher’s Name:
Medical Conditon?
 Yes
 No
Sex:
M
F
Birth date:
Postal Code:
Teacher’s Signature:
If yes, please complete Medical Form availabe from the LCMS Office
How did you hear about LCMS Summer Camps?
 Family  Friend  Newspaper (list)
 Facebook  Mail/Email  LCMS  Other (please specify)
GENERAL MUSIC & EARLY CHILDHOOD
PROGRAM
Playing with Music
Music for Babies & Toddlers
Pre-Twinkle Introductory Violin
Tuition:
$125
$80
$65
Total:
Section Total:
SUZUKI SUMMER STUDENT PROGRAMS
PROGRAM
Tuition:
Strings in Summer
$65
Total:
(by June 1)
Suzuki Summer Student Workshop
 Twinklers Mini Camp
 Strings Book 1-3
 Strings Book 4-up
 Piano/harp Book 1-3
 Piano/harp Book 4-up
 Piano Book 3 Master Class Only
$200
$300
$350
$260
$310
$80
(after June 1)
(deposit only)
$200
$350
$400
$310
$360
$80
$50
$50
$50
$50
$50
n/a
(Deposit non-refundable. Balance of fees due 4 weeks prior to course start date)
Enrichment Class Selection:
 First Choice (included in tuition, please circle class below)
#1 Fiddling  #2 Marimba for Pianists  #3 Chamber Music
#4 Japanese Arts  #5 Drumming
 Second Choice $50 (if schedule allows, please circle preferred class below)
#1 Fiddling  #2 Marimba for Pianists  #3 Chamber Music
#4 Japanese Arts  #5 Drumming
IMPORTANT! Current Piece:
Please indicate current piece, book number
and composer in the space provided 
SAA Suzuki Teacher Development Programs
SAA Number: ________________
Workshop Lunch Option (July 17-20 only)
(by June 1)
 Piano Book 3
$425
(after June 1)
$475
(deposit only)
$100
(Deposit non-refundable. Balance of fees due 4 weeks prior to course start date)
Auditor Fees: $20 Daily Auditor Fee (Student Classes Only)
$28
Section Total:
CHAMBER MUSIC
Team Music
Tuition:
Total:
(by June 1)
(after June 1)
(deposit only)
 Team Music
$295
$345
(Deposit non-refundable, balance due 4 weeks prior to course start date)
$50
 Chamber Ensemble Add-on
(Suzuki Workshop Book 4+
strings students only. Must also
be enrolled in chamber music
enrichment option.)
n/a
$80
$80
Section Total:
PAYMENT
PROGRAM TOTALS:
POLICIES & CONSENT
Deposit
For courses where a deposit is required, the balance of fees is due 4 weeks prior to the course start
date. For all other courses, the complete course fee is due at the time of registration.
Refund Policy
A full refund of course fees, exclusive of non-refundable component, may be obtained if written
cancellation notice is received by the LCMS office prior to 4 weeks of the course start date. A 50%
refund will be given for cancellation notice received between 2-4 weeks prior to the course start.
There will be no refund given for cancellations received within 2 weeks of the course start date.
I am the parent/lawful guardian of the child registered
and as such I acknowledge and agree to be responsible
for the supervision and safety of my child at all times
while he/she is on the premises and the Langley
Community Music School. Further, I accept
responsibility for damage caused to the facility by the
actions of my child, and I agree to indemnify the Music
School for any damages arising as a result of those
actions.
Signature (Parent/Guardian/Adult Student):
Privacy Policy
Your personal information (such as name, phone number, address, email, date of birth, emergency
contact) collected on the LCMS registration form will be used for school administration,
communication and accounting purposes only. We exercise care and diligence in managing,
transmitting, and securing your personal information once it is received. LCMS does not share,
transmit, or release your personal information to outside parties.
Print Name of Parent/Guardian (or Adult
Student):
**Please make cheques or money orders payable in Canadian Funds to Langley Community Music School or LCMS**
Date Rec’d:
Access:
FOR OFFICE USE ONLY
Cash Rec’d:
Chq Rec’d:
Receipt #:
#:
E-NEWSLETTER CONSENT
I give LCMS permission to send me emails regarding school news, programs, events and concerts.
Signature (Parent/Guardian/Adult Student):
PHOTO RELEASE
In registering, I understand that LCMS may take photos of student classes, presentations, recitals and events, and that these photos may be used by LCMS for
publicity purposes, including print materials (e.g. brochures) and on the school’s website and social media.
Signature (Parent/Guardian/Adult Student):