Adult Student Questionnaire
Fill out the form carefully for registration
Name
*
First Name
Last Name
What type of lessons are you interested in?
*
Please Select
Piano 101
Individual lessons (30 minutes)
Individual lessons (45 minutes)
Individual lessons (60 minutes)
Phone Number
*
E-mail
*
example@example.com
Birth Date
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2025
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1921
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Year
Gender Identity
Please Select
Male
Female
Non-Binary
Other
Prefer not to answer
What are your preferred pronouns?
Address
*
Street Address
Street Address Line 2
City
State
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?
*
Yes
No
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?
Theory
Technique
Rhythm / Counting / Metronome
Ear Training
Sight-reading
Fingering
Phrasing
Improvising
Composing
Memorizing
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?
Yes
No
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?
Any food or other allergens I should be aware of?
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.
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.
To take and use photographs of me for promotional or educational purposes on the website and other educational or promotional materials used by the MUSIC INSTRUCTOR.
*
This authorization ☐ includes or ☐does not include permission to utilize my name in conjunction with the photographs.
*
includes
does NOT include
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.
*
This authorization ☐ includes or ☐does not include permission to utilize my name in conjunction with the video.
*
includes
does NOT include
Today's Date
-
Month
-
Day
Year
Date
Signature of Parent (for children) or Student Signature (for adults)
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