Name of Student_____________________________________ Grade_____ Age ______

Address_______________________________________________________________________

Phone_______________    E-mail __________

Using Accompanist Circle YES or NO

Teacher's Name __________________________ Phone ____________E-mail ________

Address______________________________________________________________

Teachers: Enter preferred dates and time for helping as MONITOR, as needed ________

Teacher membership in ASTA with NSOA is required.

The signature(s) below indicate(s) that I understand the rules governing this event and agree to abide by them.

Teacher's signature: ___________________________________________

Teachers, please duplicate applications as needed. Collect all fees and application forms.

Make out one check to Tennessee-ASTA, and send to:

Francis Elliott, Certificate Program
c/o: The Music Academy
2819 Hwy 70 North, Crossville, TN 38751
Tel: (931) 484-6676
email: themusicacademy@volfirst.net

Instrument ______________________________________ Level_______

Check box if appropriate:  Level B   Comments Only   Honors 

Works to be performed:

1. Title_______________________________ mvt ____ Composer _________________

2. Title_______________________________ mvt ____ Composer _________________

3. Title ______________________________ mvt ____ Composer _________________

4. Etude ______________________________________ Composer _________________

5. Scales and Arpeggios ___________________________________________________