Student Registration Form

STUDENT INFORMATION

#1. Student's first and last name

Birthdate

School and grade

Are there special circumstances of which the teacher should be aware (allergies, special needs, health problems, learning disabilities, etc.)?

No
Yes

If yes, please explain.

#2. Student's first and last name

Birthdate

School and grade

Are there special circumstances of which the teacher should be aware (allergies, special needs, health problems, learning disabilities, etc.)?

No
Yes

If yes, please explain.

#3. Student's first and last name

Birthdate

School and grade

Are there special circumstances of which the teacher should be aware (allergies, special needs, health problems, learning disabilities, etc.)?

No
Yes

If yes, please explain.

FAMILY INFORMATION

Mother's first and last name

Mother's cell phone number

Mother's email address

Father's first and last name

Father's cell phone number

Father's email address

Student's home address

Home phone number

Person responsible for payment

Email monthly statement to this email address

OTHER INFORMATION

Are there religious beliefs or other circumstances that might impact repertoire choices or performance dates or performance venue?

No
Yes

If yes, please explain.

Permission is given for each students' photo to be used for the studio website and Facebook purposes.

Yes
No

Please include my name and contact information on the swap list for Extended Absences.

Yes
No

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

Yes
No