Academy of Irish & Cultural Studies
Registration Form

Name

Parent/ Guardian Name (if student is under 18)

Phone Number

Home:
Mobile
Work

Mailing Address

Street/ P.O. Box



City State Alabama Alaska APO/FPO - Africa APO/FPO - Canada APO/FPO - Americas APO/FPO - Europe APO/FPO - Middle East APO/FPO - Pacific Arizona Arkansas California Colorado Conneticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode

E-mail Address

Emergency Contact

Emergency Contact Phone

Class Accordion Bagpipes Banjo Bodhran Ceili Dancing Fiddle Flute Harp Guitar Irish Language Mandolin Piano/Keyboard Pipe Drumming Scottish Gaelic Scottish Highland Dancing Step Dancing Welsh Language Whistle/Flute

Payment will be made via telephone reply.

Notes / Additional Information