piano_student_registration_form__1_.doc |
PIANO STUDENT - REGISTRATION INFORMATION
DATE _________________________________________
STUDENT NAME _______________________________________________________________________________________________________________________
ADDRESS _______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
CONTACT (Parents See Below):
HOME PHONE _________________________________
CELL PHONE _____________________________________
EMAIL (For Piano Information): _________________________________________________________________________________________________________
EMERGENCY CONTACT:____________________________________________________________________________________________________________
FAMILY NAMES AND CONTACTS
Mother/Spouse_________________________________________________ Father/Spouse__________________________________________________
Cell Phone ______________________________________________________
Cell Phone ______________________________________________________
Brothers/Sisters ________________________________________________________________________________________
STUDENT
Age/Birthday _______________________________________________
School/Grade _____________________________________________________
Starting Date _______________________________________________
Lesson Time _____________________________________________________
Lesson Fee ______________________________________________ (per visit)
LESSONS
Level of Play ________________________________________________________________________________________________________________________
Purpose of Lesson ____________________________________________________________________________________________________________________
Area to work on ______________________________________________________________________________________________________________________
SPECIAL NEEDS OR CONSIDERATIONS (How to Handle) ____________________________________________________________________________
_______________________________________________________________________________________________________________________
REFERRAL FROM (circle one): Friend ___________________________________________________________________________
Website
POLICIES AND PROCEDURES:
Received __________________
Read ______________
Signed and Turned into Studio___________________________
DATE _________________________________________
STUDENT NAME _______________________________________________________________________________________________________________________
ADDRESS _______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
CONTACT (Parents See Below):
HOME PHONE _________________________________
CELL PHONE _____________________________________
EMAIL (For Piano Information): _________________________________________________________________________________________________________
EMERGENCY CONTACT:____________________________________________________________________________________________________________
FAMILY NAMES AND CONTACTS
Mother/Spouse_________________________________________________ Father/Spouse__________________________________________________
Cell Phone ______________________________________________________
Cell Phone ______________________________________________________
Brothers/Sisters ________________________________________________________________________________________
STUDENT
Age/Birthday _______________________________________________
School/Grade _____________________________________________________
Starting Date _______________________________________________
Lesson Time _____________________________________________________
Lesson Fee ______________________________________________ (per visit)
LESSONS
Level of Play ________________________________________________________________________________________________________________________
Purpose of Lesson ____________________________________________________________________________________________________________________
Area to work on ______________________________________________________________________________________________________________________
SPECIAL NEEDS OR CONSIDERATIONS (How to Handle) ____________________________________________________________________________
_______________________________________________________________________________________________________________________
REFERRAL FROM (circle one): Friend ___________________________________________________________________________
Website
POLICIES AND PROCEDURES:
Received __________________
Read ______________
Signed and Turned into Studio___________________________