Jazz Kiln Registration

Student Information
Student Name*
FirstLast
Gender*
- Male
- Female
Student Address*
Street AddressCityZip / Postal Code
Student Phone*
Student Email
We primarily contact all applicants and parents by email. If you do not have an email address that you check regularly please indicate in the notes the best way for us to contact you.
Instrument*
If multiple instruments, please just list instrument to be focused on during the workshops.
Years Played*
List Bands or Programs you perform with regularly
Current Music Instructor
Music Instructor - phone or email
Select One*
- 17 years or younger
- 18 - 30
- 31 - 50
- 51 and above
Which Level are you signing up for? *
- Level I (5:45 - 7:10pm)
- Level II (7:30 - 8:55pm)
- Not Sure
Contact the office with questions and we will help guide you to the right class, 831-427-2227.

Parent/Guardian Information
Parent/Guardian Name*
FirstLast
Parent/Guardian Name
FirstLast
Is the parent's address the same as the student's?*
- Yes
- No
Parent/Guardian Address
Street AddressCityZip Code
Parent Phone*
Email
We primarily contact all applicants and parents by email. If you do not have an email address that you check regularly please indicate in the notes the best way for us to contact you.
Emergency Contact
Emergency Contact's Name*
FirstLast
Emergency Phone*
Relationship to student
Payment Information
Registration is $200. You may also complete, print, and fax or mail this form to: Kuumbwa Jazz 320-2 Cedar Street Santa Cruz, Ca 95060 Fax: (831) 427-3342 Phone: 831-427-2227
Credit Card Type
- Visa
- Master Card
Credit Card Number*
Exp Date*
Security Code*
*located on the back side of the card
How did you hear about these workshops?*
Do you have more to add? Let us know here!

Kuumbwa Jazz