Enrollment Form

Date:

Student General Information

Student's Name:

Age:

Birth Date:

Mailing Address:

Home Phone:

Email:

Grade:

Type of Lesson you are interested in:

Previous & Current Musical History:

Student has studied piano and/or voice for: years

    Other Instruments Studied:

Is this student involved in musical groups? What type & Where?

Other Extra Curricular Activities:

Parent's General Information

Parent's or Guardian's Names:

Parent's Email Address

Parent's Email Address

Mother's Work Phone:

Father's Work Phone:

Emergency Information

In the event of an emergency, please contact: Parent's Cell Phone:

Alternate Contact:

Alternate Phone Number

Relationship:

This student is allergic to:

About Your Piano

Do you have a piano at home? Yes No   

Date acoustic piano was last tuned?

How did you hear about us?

Day & Time preferred for weekly lesson: