Date:
Student's Name:
Age:
Birth Date:
Mailing Address:
Home Phone:
Email:
Grade:
Type of Lesson you are interested in: Piano Ukulele Guitar Voice Combination Piano & Voice Group Lesson Individual Lesson
Length of Lesson: 30 Minute 45 Minute 60 Minute
30 Minute 45 Minute 60 Minute
Student has studied piano, guitar and/or voice for: years
Other Instruments Studied:
Is this student involved in musical groups? What type & Where?
Other Extra Curricular Activities:
Please provide any information here you believe to be important for the teacher to know.
Parent's or Guardian's Names:
Parent's Email Address
Mother's Work Phone:
Father's Work Phone:
In the event of an emergency, please contact: Parent's Cell Phone:
Alternate Contact:
Alternate Phone Number
Relationship:
This student is allergic to:
Do you have a piano at home? I have a piano at home I do not have a piano at home
I have a piano at home
I do not have a piano at home
Date acoustic piano was last tuned?
How did you hear about us?
Day & Time preferred for weekly lesson:
