FILL OUT THE FORM AND FAX TO

39  0427  41251

Name / Surname ____________________________________________________________________

birthplace _____________________________________________________

date ___-___-_____

living place ____________________________

State/region ______________

CAP _________

Adress _______________________________________________________

n. ____________

Phone _________________________________

E-mail ______________________________

Musical Instrument ____________________________

Years of study _______________________

Music education:

Music School

Conservatory

Self-educated

I ask to be registered for the International Courses, class of    _____________________

Full accomodation (night, 2 meals a day)

Yes

No

Night only

Yes

No

Prenotazione solo pasti

Yes

No

The organisation reserve the rights to apply modification to the condition

To send with the compiled form:

A) Copy of payment form.

I autorize the Istituto Fano to treat my personal data conforming to the italian law on privacy. The data will be used for the registration needs and only in order to promote future activities of the Istituto Fano.

I've read and accepted the terms for the inscription.

ACCEPT                DECLINE

Date and place

________________

Signature

_________________

Signature of a parent for under age students

_________________________________