Registration Form

Student Name*

Date of Birth (if under 18 - N/A if Over 18)*

Student Phone Number*

Student Email*

I would like to receive SMS text message reminders before each lesson

I would like to receive email reminders before each lesson

Medical conditions or special considerations we need to be aware of?

Instructor Name

Musical Discipline (Instrument)

Start Date (if known)

Preferred Lesson Type*

Primary Contact Name*

Primary Contact Number*

Primary Contact Email*

Primary Contact Mailing Address*

Secondary Contact Name (if applicable)

Secondary Contact Number

Secondary Contact Email

Emergency Contact Name & Number*

Signature (Parent Signature if under 18)*

Date*

I have read & understand the General Payment & Cancellation Policy listed below*