Carol's Piano Studio

#1 Student name

Birthdate (mm/date/year)

School and grade (ex. Harmony, 3rd)

Are there special circumstances that the teacher should be aware of? (ex. allergies, health issues, special needs, other accomodations?) Please explain.

#2 Student name

Birthdate (mm/date/year)

School and grade (ex. Harmony, 3rd)

Are there special circumstances that the teacher should be aware of? (ex. allergies, health issues, special needs, other accomodations?) Please explain.

#3 Student name

Birthdate (mm/date/year)

School and grade (ex. Harmony, 3rd)

Are there special circumstances that the teacher should be aware of? (ex. allergies, health issues, special needs, other accomodations?) Please explain.

Mother's name

Mother's email address

Mother's cell phone number

Father's name

Father's email address

Father's cell phone number

Mailing address

Person responsible for payment

Email monthly invoices to this email address

Perferred lesson model

In-person lessons - 30 minutes
Online lessons - 30 minutes
In-person lessons - 60 minutes
Online line lessons - 60 minutes

Photo release: I give permission for each student's photo/video to be used by the studio. For example: on studio bulletin boards, in newletters, on the Studio website, photo displays at recital, recital videos posted on Studio YouTube channel.

Yes, I give full permission
No, I do not give permission

I would like to be included in the swap list for extended absences.

Yes, include me!
No, do not include me.

I have read and understand the Studio Policy and agree to abide by the terms of the policy.

Yes, I agree.
No, I do not agree