New Student Registration Form
Student Information
Student Name
*
First Name
Last Name
Student birth date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have additional students that will be registering as well? If so, please indicate their name and age below. (You will have to register each student separately.)
Parent/Guardian 1
*
First Name
Last Name
Relationship to student
*
Self
Parent
Guardian
Relative
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Parent/Guardian 2
First Name
Last Name
Relationship to student
Self
Parent
Guardian
Relative
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Lesson Information
I am registering the student for (select all the apply)
*
30-minute PIANO lessons
45-minute PIANO lessons
60-minute PIANO lessons
30-minute VOICE lessons
45-minute VOICE lessons
60-minute VOICE lessons
30-minute ORGAN lessons
45-minute ORGAN lessons
60-minute ORGAN lessons
Does the student have any music experience (previous lessons, choir, etc.)
*
Yes
No
If yes, please describe:
Additional Information
Emergency Contact (NOT parent or guardian)
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
*
example@example.com
Please list any allergies, medical conditions, etc. that you would like us to be aware of
Payment
My preferred method of payment is:
*
Cash
Check
Card (via Stripe)
If using a debit or credit card, I understand that my card will be charged monthly in advance of lessons and consent to these charges. I understand that I will receive a manual invoice for the first month of payment. The card used to pay that invoice will then be charged to pay for subsequent months.
Yes
No
I will pay my student's tuition on
The 1st of each month
The 15th of each month
Acknowledgement and Signature
In addition to this form, I understand that I must also pay a $25/student registration fee and fill out the Practice and Conduct Agreement and Media Waver. I understand that my student's registration will not be considered complete until payment is received and the Practice and Conduct Agreement and Media Waiver are signed. The application fee can be paid at https://buy.stripe.com/eVqaEWgUR0Vr3I65znds400
*
Yes
No
Signature
Submit
Submit
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