Child Student Registration Form

Child Student Questionnaire

Fill out the form carefully for registration
Name*

First NameLast Name
What kind of lessons are you looking to enroll in?
Nickname
Birth Date*

MonthDayYear
Grade in School
School Name and Neighborhood
Gender Identity
What are your preferred pronouns?
Why do you want to learn to play the piano? Any specific goals?
What are your other extra-curricular activities, interests and hobbies?
What are your thoughts about performing in school talent shows, in recitals or competing?
Have you ever studied music before whether at school, in choir, or on another instrument?*

YesNo
Do you have any other friends who play piano?
Are you willing to commit at least four days per week to practicing?

YesNo
What times in the day and week do you think you can dedicate to practicing?
Do you understand the studio policies and promise to be prepared for lessons?
Will you be willing to participate in all studio events, festivals, theory exams and requirements?
Are there any questions you have for me, as your piano teacher?
Student Signature*

Clear
Parent/Guardian Information

(for Parent of Student to complete)
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #1 Phone*
Please enter a valid phone number.
Parent/Guardian #2 Phone
Please enter a valid phone number.
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #2 Email
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If your child is being cared for on a regular basis by someone other than the parent, please provide the name and cell number of the person:
How did you hear about Music with Monique? (Name of referral)
Do you have any other children (ages, names)?
Does anyone in the family play piano or other musical instruments?
What are your goals for your child as a piano student?
Are you interested in your child’s participation in performance opportunities and competitions?
Does your child have any learning challenges, or difficulty focusing or paying attention? Any other behavioral issues discovered in school?
What kind of piano do you have?
If acoustic, do you have a regular tuner?
Is the piano in a space that provides a supportive learning environment? (Quiet, well lit, free of distractions)

YesNoLet's discuss how best to make this happen
Will you ensure that your child is aware of his weekly music assignments and that practicing is as prioritized as school assignments?

YesNo
How do you plan on supporting your child with their musical education?
What expectations do you have of me as a piano teacher?
Any food or other allergens I should be aware of?
Any other thoughts/questions/comments?

	Date(s)
First day of school
Fall Break
Thanksgiving Break
Winter Break
First day of school January 2022
Other known days off from school
Known extended trip/vacation dates

Your signature below indicates that you have read and understand the teaching policies of my studio and that all information provided is accurate and comprehensive:*

Clear
PHOTOGRAPH AND VIDEO AUTHORIZATION FORM

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. *

Clear
This authorization ☐ includes or ☐does not include permission to utilize my name in conjunction with the photographs.*

includesdoes 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.*

Clear
This authorization ☐ includes or ☐does not include permission to utilize my name in conjunction with the video.*

includesdoes NOT include
Today's Date

MonthDayYear
Date
Signature of Parent or Guardian of student*

Clear
Should be Empty:

Child Student Questionnaire

Parent/Guardian Information

PHOTOGRAPH AND VIDEO AUTHORIZATION FORM