Student Information Form

Please take a few moments to fill out the following questions so we can better serve you!

Student Information

Name

Age:

Date of Birth:

School:

Grade:

Parent(s) Names:

Physical Address

City

State

ZIP Code

Mailing Address
(if different from physical address)

City

State

ZIP Code

Contact Information

Home Phone (required)

Cell Phone (required)

Do You Text?

YesNo

Email to Send Billing Information (required)

Preferred Method of Contact

Home PhoneCell PhoneEmail

How did you hear about us? (Current clients receive a free lesson for each referral, so please be specific!)

What type of instrument do you have at home?

Would you like to be placed on our piano sale information list?

Student hobbies/interests or extra curricular activities:

Musical background/previous experience/current materials used:

Does anyone in the family play any musical instruments?

Please estimate how long the student will be able to practice each day:

What would be your current lesson time availabilities (Day/Time estimates)?:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Any concerns or other information you would like your teacher to know?

I am not a Robot.