2010 Membership & Concert Registration
 

[Click Here] for a printable registration form for mailing instead of using this on-line version
 

Please submit one form per person. You may also wish to print a copy of the completed form for your own records.

Personal Information:
* - Required Fields

 Name* (first)*(last)

*Home #  

Area code   
 -
 Home Address*

 Business  or Cell #  

Area code
-
 City*              State *  

 FAX #  

Area code
-
 ZIP*              E-Mail *   
 Occupation New Member ?  Yes   No
 Medical Specialty (If applicable) Gender: Male Female
 Musical Experience (if new member) (Please indicate if you can serve as soloist, section leader, Principal)
 How did you hear about our group?
* I prefer to receive updates by (check one)  Email (saves postage)  US Postal
 
 Please indicate your performance status: Vocalist Instrumentalist Companion
Voice: S1S2AT1T2B1B2   Instrument:
 Any Special Requirements?

REGISTRATION FEES
Registration fees are $100.00 annually per individual (no family registration). By paying registration fees, you receive mailings, reports, and information about U.S. and overseas tours and performances.
  Please check which concerts you will participate in:
     
Please consider making an optional, supporting Veterans Day (Washington, D.C.)

Nov. 10, 2010  YesNo
contribution. You will be Trip: (Paris & Brussels)

Nov 11-21, 2010  YesNo
prompted after you submit this form.    
   

 
  Registration Fee (yearly):  $ 100.00
     
Registration fees are refundable if you are not accepted for this years program. Registration is open to VA, non-VA, medical and non-medical individuals. If you need a receipt, please print this page and send to our address below and enclose a stamped self-addressed envelope. For more information, contact us at: (202) 797-0700 or toll free (888) 6-Do-Re-Mi (888-636-7364). FAX: 202-797-0771.

VA-NMMG, Attn: Robert Wisleder, 45 Kimball Beach Road, Hingham, MA 02043-1145


 

Payment Method

Credit Card Personal Check
 

VA-National Medical Musical Group is not a government agency.
Last revised: June 28, 2010