Student Information Student Name*
Birthdate*
Age*
Grade*
Contact Information Parent/Guardian Names*
Home Phone
Cell
Other Phone
Email*
Mailing Address*
City*
Postal Code*
Please answer the following questions pertaining to the student: What is the main reason or goal for wanting to take piano lessons?
Tell me a bit about the student. (ie. personality, learning style, hobbies etc.)
Are there any behavioral/learning anomalies you would like me to be aware of?
Does the student have any allergies/medical conditions you would like me to be aware of?
Lesson Scheduling - Please specify what days and times works best for you. I will do my best to accommodate all requests, I can not guarantee that you will be given a spot in your top 3 selections.
