paper form registration, for credit - Potomac Arts Academy

Registration Form - Rolland String Pedagogy Workshop Summer 2015
FOR GMU GRADUATE/ UNDERGRADUATE CREDIT
Name_______________________________________________ Date of Birth ________________________
Address___________________________________ City___________________ State ______ Zip_________
Email ___________________________________Phone ____________________ Cell ___________________
Additional Contact Info _________________________________________
☐ Male
☐ Female
Please specify any special needs or limitations of participant: ___________________________________________
____________________________________________________________________________________________
Paul Rolland String Pedagogy Workshop | July 27- 31, 2015 | (other fees may apply - see website!)
Course# MUSI 492 603 Selected Topics in String Pedagogy (3 credits)
In State Tuition
□ $1,560
Out-of State Tuition
□ $1,836
PARKING INFORMATION
If you plan on parking a vehicle on the GMU campus during program hours, you are required to have a temporary GMU weekly parking pass. Passes - which are good for Lot K on campus - are available for $25 per week A parking pass is ONLY necessary if the participant will be parking their car for an extended period of time. If the participant will only be doing a Drop-Off/
Pick-Up, a parking pass is NOT necessary. Visitors may also park in the Mason Pond Parking Deck for $14 per day.
TO PURCHASE YOUR GMU PARKING PASS ONLINE AND PRINT AT HOME, GO TO:
http://potomacacademy.gmu.edu/PDFs_Forms/ParkingPassSummerProgramInstructions2015.pdf
Payment Options:
Please make checks payable to George Mason University
□ Pay in full with check
□ Pay in full with credit card (Mastercard or Visa only)
Total Amount Enclosed
$__________________
Credit Card Number ______________________________________Expiration Date ____________________
Name on Card ____________________________________________________________________________
Signature for payment ______________________________________________________________________
REQUIRED: COMPLETE CREDIT CARD BILLING ADDRESS (Your registration will not be processed without this)
Address __________________________________________________________________________________
City _______________________________ State ___________ Zip _________________________________
Note: We reserve the right to cancel or postpone any program or activity due to inclement weather or low enrollment. A service fee will
be imposed for all returned checks and could result in refusal of future participation. All tuition costs include a $50 non-refundable
cancellation fee, except when classes are cancelled by Potomac Arts Academy.
Participant Waiver: In consideration of my, and/or my childs, participation in this activity I hereby release and discharge the
Organiztion, and its representatives, successors and assignors, from any and all liability arising from accident, injury and illness that I (he/
she) may suffer as a result of my (our) participation in this activity. I (we) also will follow the rules and regulations set out by the
Organization and above named parties. Parent or guardian must sign for anyone age 18 and under. I do hereby grant and give these
groups the right to use my and my child(s) photograph, image or video both singly and in conjunction with other persons or objects and
presentations, advertising, publicity, and promotion relating thereto.
Signature _____________________________________________________________ Date __________________________
Please mail or fax this
form along with
payment to:
George Mason University
Office of Continuing Professional Education
4400 University Dr, MS 2G2
Fairfax, VA 22030
Secure Fax: (credit card only)
703-993-2121
ATT: Rolland Strings Coordinator
www.PotomacAcademy.org