Student Name: _____________________________________ Birthdate: ___/___/______

Parent/Guardian Name: ______________________________________________________

Parent Email Address: ______________________________________________________

Phone: _________________________________ Can receive texts? ______

Home Address: _______________________________________________________________

(2nd Parent/Guardian Name:_______________________________________________________

Phone:_________________________ Can receive texts? _____

Email Address: _________________________ )

Student Phone: __________________

Student Email Address: ___________________

Emergency Contact Name & Number: ____________________________________________

Has your child had piano lessons before? If yes, what is the length of study and what music books is your child using? ______________

Where did you hear about this studio?___________________________

Additional Comments/ Describe your availability during the school year ________________________________________________________________________________

_________________________________________________________________________________


Any allergies/medical concerns or other comments?
__________________________________


Adult student registration-

Student Name: _____________________________________ 

Email Address: ______________________________________________________

Phone: _________________________________ Can receive texts? ______

Home Address: _______________________________________________________________

Emergency Contact Name & Number: _____________________
Has your child had piano lessons before? If yes, what is the length of study and what music books is your child using? ______________

Where did you hear about this studio?___________________________



Additional Comments/ / Describe your availability during the school year ________________________________________________________________________________

_____________________________________________

Allergies/ Medical or other concerns?