Waiting List Registration Form

Waiting List Registration Form

Fill out the form carefully for registration
Contact Name (parent/ carer if student is under 18 years)

First NameLast Name
Contact email (parent/ carer if student is under 18 years)*
example@example.com
Contact mobile phone (parent/ carer if student is under 18 years)*
Please enter a valid phone number.
Student Name*

First NameLast Name
Date of birth of Student*

DayMonthYear
Preferred pronoun*
Address of Student*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School attended by Student*
Student's current academic year*
Name of any other family members currently registered with Encore Music (if applicable)
I am interested in (tick all that apply):

Piano lessons: 1:1 at the Horsham StudioPiano Lessons: Home Visits in Battersea/BalhamPiano lessons: at Alderbrook School, BalhamPiano lessons: onlineMusic Theory: group course online
Current piano ability of student*

Beginner (no previous experience)Early Learner (up to Grade 2 standard)Improving Player (Grade 3-5 standard)Experienced Performer (Grade 6 standard and above)Returner (please state previous achievements below)
Previous musical experience
Please include name(s) of teacher(s), graded exams, recital/festival experience and any other instruments if applicable
Any other information you think we should know
I have read, understood and accepted the Privacy Notice*

Yes
We would like to send you information about our services, by telephone, email and/or SMS. Please note that if you consent to being sent our information by email then your data will be shared with the third party organisation Mailchimp who will make contact on our behalf. If you agree to being contacted this way, please tick the relevant boxes:

EmailPhoneSMS
Should be Empty: