Northern Lights Online Piano Festival

STUDENT CONTACT INFORMATION

**Please enter student's name, not parents.

Student's Surname: Student's Given Name and Middle Initials Street Address: City: Province: Postal Code: Telephone: email:

TEACHER CONTACT INFORMATION

Teacher's Surname Teacher's Given Name & Initial: Street Address: City: Province: Postal Code: Telephone: email:

Please paste your YouTube video link here: Title(s) / Composers(s) / Collection Title & Page Number :

Should I be a scholarship recipient I will sign a media release form allowing Northern Lights CNCM to share my video submission on the CNCM YouTube channel. Note: parents/guardians of participants under the age of 18 will sign the media release form for their child.

I agree to the conditions in the above statement TOTAL FEE ENCLOSED: