CSMA Registration Form
Please print out & mail with payment to CSMA
Student Name ____________________________________  
Date of Birth (under 18) __________________  
Class Number __________________  
Class Name ____________________________________
Cost $___________
     
Student Name ____________________________________  
Date of Birth (under 18) __________________  
Class Number __________________  
Class Name ____________________________________
Cost $___________
     
Student Name ____________________________________  
Date of Birth (under 18) __________________  
Class Number __________________  
Class Name ____________________________________
Cost $___________
Add Yearly Individual Membership ($55.00)
$___________
Add Yearly Family Membership ($90.00)
$___________
Contribution to the CSMA Scholarship Fund!
$___________
Total:
$___________

Please charge my credit card (Visa/Mastercard Only):  
Card # ____________________  
Expiration Date _____________  

Parent/Guardian or Adult Student Name _____________________________
Phone (H) ____________________
Address _____________________________
Phone (W)____________________
  _____________________________ Email ________________________
  _____________________________  
Signature ___________________________________
(Parent/Guardian must sign if student is under 18 yrs. old)

Please note: A medical release form must be on file at the office before students 18 or younger may begin activities at CSMA.

CSMA, 330 East State Street, Ithaca, NY 14850