Adult Student Registration Form

Adult Student Questionnaire

Fill out the form carefully for registration
Name*

First NameLast Name
What type of lessons are you interested in?*
Phone Number*

Country CodeArea CodePhone Number
E-mail*
example@example.com
Birth Date*

MonthDayYear
Gender Identity
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Why do you want to learn to play the piano? Any specific goals?
What are your other interests and hobbies?
Field of Work / Educational Background
Have you ever studied music before whether at school, in choir, or on another instrument?*

YesNo
If Yes, What did you like / not like about studying with your former teachers?
If Yes, What was the highest level of performance you achieved (if you used method books) or what pieces are you most proud of learning?
If you've studied piano before: Which of these foundation areas have you studied?

TheoryTechniqueRhythm / Counting / MetronomeEar TrainingSight-readingFingeringPhrasingImprovisingComposingMemorizing
Which foundation areas would you like to have more experience studying?
What are your thoughts about performing in recitals or in front of friends?
Are you willing to commit at least four days per week to practicing?

YesNo
What do you perceive being your biggest obstacles for practice?
How do you plan to overcome these obstacles?
Are there any questions you have for me, as your new piano teacher?
How did you hear about Music with Monique? (Name of referral)
Do you have any learning difficulties I should be made aware of?
What kind of piano do you have?
If acoustic, do you have a regular tuner?
Is your piano in a space that is quiet, well lit, free of distractions?
What expectations do you have of me as a piano teacher?
Your signature below indicates that you have read and understand the teaching policies (link) of the Music with Monique studio and that all information provided is accurate and comprehensive.

Clear
PHOTOGRAPH AND VIDEO AUTHORIZATION

By signing your initials next to the corresponding activity set for below, I am authorizing the MUSIC INSTRUCTOR to undertake that activity for me and/or my child. This decision is revokable at any time in writing. Recordings are made during group classes and recitals. Private lessons are never recorded unless upon student request.
This authorization ☐ includes or ☐does not include permission to use PHOTOGRAPHS of me for educational or promotional purposes on the website and other educational and promotional materials.*

includes permission to use photographs with first name (Student first names are only listed when celebrating an accomplishment. You will always be asked beforehand. Otherwise names are never used).includes permission to use photographs without namedoes NOT include permission to take photographs
This signature authorization includes permission to take photographs of me for promotional or educational purposes on the website and other educational or promotional materials used by the MUSIC INSTRUCTOR.

Clear
This authorization ☐ includes or ☐does not include permission to use Videos of me for educational or promotional purposes on the website and other educational and promotional materials.*

includes permission to use VIDEOS with first name (Student first names are only listed when celebrating an accomplishment. You will always be asked beforehand. Otherwise names are never used). Please be advised that for internal group class recordings, your zoom or other video conferencing name may be listed.includes Video permission to use photographs without namedoes NOT include permission to take video (please be mindful during group online classes).
To take and use video of me for promotional or educational purposes on the website and other educational or promotional materials used by the MUSIC INSTRUCTOR.

Clear
Today's Date

MonthDayYear
Date
Signature of Parent (for children) or Student Signature (for adults)

Clear
DATA AUTHORIZATION

Please see separate form
Should be Empty:

Adult Student Questionnaire

PHOTOGRAPH AND VIDEO AUTHORIZATION

DATA AUTHORIZATION