Music School Registration Form

NEW STUDENT REGISTRATION FORM & QUESTIONNAIRE
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Preferred Contact Method*

PhoneEmail
Secondary Phone Number
Please enter a valid phone number.
Would you like to focus on Acoustic OR Electric guitar?*

STUDENT QUESTIONNAIRE
Check any genres that interest you.

RockBluesJazzMetalClassicalFolkPopElectronic
Prior Guitar Playing Experience (number of years)*
Name some of your favorite Bands/Artists.*
Name some songs you'd like to be able to play on guitar someday.*

Parent/Guardian Information

Only required if student is under 18y/o.
Parent/Guardian Name

First NameLast Name
Additional Parent/Guardian Name

First NameLast Name
Does your child have any medical conditions or special considerations we need to be aware of?

YesNo
If you answered "Yes" to the above question. Please list any concerns, considerations, or requests below.
All parents/guardians are welcome to sit in on lessons for their entire duration. Parents can also drop their child off for the lesson, then return to pick them up later. If you plan to drop off your child for their lesson then have someone else pick them up, that person will need to be listed below as an authorized person.

In the event that no parent/guardian nor any authorized person is available, then a Parent/Guardian will need to confirm via phone that someone else will be picking their child up for the day.

All Easy Pickin' instructors are required to maintain their PA Child Abuse History (CY113) and Pennsylvania Act 126 Child Abuse Recognition and Reporting Training certifications.
Authorized Person #1

First NameLast Name
Phone Number
Please enter a valid phone number.
Authorized Person #2

First NameLast Name
Phone Number
Please enter a valid phone number.
Authorized Person #3

First NameLast Name
Phone Number
Please enter a valid phone number.
Authorized Person #4

First NameLast Name
Phone Number
Please enter a valid phone number.
Authorized Person #5

First NameLast Name
Phone Number
Please enter a valid phone number.
Signature of Parent/Guardian

Clear
I certify that the above information is accurate and that all individual(s) listed as Authorized Persons are approved person(s) for the pick-up of my child from Easy Pickin' guitar lessons.
Date

MonthDayYear
Date
Should be Empty:

NEW STUDENT REGISTRATION FORM & QUESTIONNAIRE

STUDENT QUESTIONNAIRE

Parent/Guardian Information