PLEASE PRINT and MAIL THIS APPLICATION FORM WITH YOUR DEPOSIT.

• Please complete the application below and mail it with your deposit of $400.00 by June 21, 2010
  to Hope & Bob Pettegrew, 117 Middle Road, Hancock, NH 03449.
• All checks should be made payable to Piano'Scape.
• The balance of the fees will be due no later than July 10, 2010 please

Cancellations received after July 10 will forfeit the deposit.

Please Print Clearly

Name_________________________________________________________________________________________
Address_______________________________________________________________________________________
Home Phone_____________________________________ Work Phone ___________________________________
E-mail_________________________________________Occupation _____________________________________
Do you have special dietary requests?______________________________________________________________
Do you have a teacher now?_____________
What are you currently studying?__________________________________________________________________
______________________________________________________________________________________________
How long have you been working on this/these piece(s)?_______________________________________________
Do you wish to study Classical, Jazz, or Swing (any combo)?____________________________________________
Describe your skill level:_________________________________________________________________________
Is it at the performance or study level?_____________________________________________________________
What are your goals for the week?________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are there specific topics of particular interest to you (in Classical, Jazz or Swing)
that you want to hear/learn about?_________________________________________________________________
_____________________________________________________________________________________________

Approximate time of arrival on registration day: Aug. 15^th____________________________________________
(  ) I prefer a single room.
(  ) I prefer to share a room with another Piano'Scape student.
(  ) I plan to share a room with a non-student.

Deposit Amount Enclosed: $________

Signature__________________________________________      Date__________________________________

Reservations are limited. Please complete and return this form at your earliest convenience along with your deposit.

For More information, call Hope and Bob Pettegrew at (603) 525-4920 or email us at

Piano'Scape

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