ETB Course Booking

Parent/Guardian 1

Parent/Guardian 2

Title *

First Name *

First Name

Surname *

Surname

Home Phone *

Home Phone

Mobile Phone *

(numeric only e.g. 0871234567)
Note: Mobile number used to set up Account

Mobile Phone

(numeric only e.g. 0871234567)

Email *

Email

Confirm Email *

Note:Email Address used to set up Account

Confirm Email

Address is different from Student

County *

County

Emergency Contact No *

First Name *	Address Line 1 *
Surname *	Line 2 *
Date of Birth *	Line 3 *
Gender *	Line 4
PPS No.		Line 5	Telephone No.
School Level
Current School
If still attending Primary School, Future Secondary School
E-mail *	Confirm Email *
Mobile *

Please tick if you are a beginner
Are any family members already attending? *
If Yes, please enter Family ID
Do you have a piano at home? *
Have you had music tuition previously? *
If Yes, please give details of exams/standard/instrument
Other information in relation to the applicant

Centre Name	Green Hills College
	32 The Hill Co Dublin
	32 The Hill Co Dublin
	32 The Hill Co Dublin
	32 The Hill Co Dublin
	32 The Hill Co Dublin
Phone	059-8633270
Fax	059-8632460
Person to contact	Co ordinate in Greenhills
Email	agreenhillscordinator@eircom.net

12345678901234567890123456789012345678901234567890

How did you hear about us?
Please indicate which advert Please indicate which magazine Please describe

Please confirm you have read and accepted the terms and conditions by ticking the box
Please confirm you have read and understand the Data Protection Act by ticking the box
Please note that the email and mobile number provided in Parent/Guardian 1 above will be assigned to this application and must be referenced in all future communication with the music school.