Piano Lesson Application Form
Please help us assess the student’s suitability for piano lessons at our academy. All information will be kept confidential.
Student Name
*
First Name
Last Name
Gender
Male
Female
Non-binary/other
Child's Age (ages 5-18 only)
*
Child's School
Does the child sing simple songs such as The Alphabet Song and Happy Birthday?
*
Yes
No
Does the child know the alphabet and numbers up to 10?
*
Yes
No
What kind of keyboard do you have at home?
*
Acoustic/hybrid piano (upright, grand, spinet)
Digital keyboard (88 keys, weighted action)
None, but ready to purchase one of the above
None
Please describe reasons for seeking piano instruction, such as interest, family musical background, or other influences/educational philosophy.
*
Preferred Lesson Day
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Family Information
Parent/Guardian Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who will supervise piano practice (please note, all children accepted must have a dedicated supervisor responsible for ensuring that the student practices four days per wek)?
*
If one of our clients referred you, please name them here
Submit Evaluation
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