Student Questionnaire

My Music Room Student Questionnaire
Student's Name*

First NameLast Name
Date of Birth
E-mail #1*
E-mail #2*
Cell Phone*

Area CodePhone Number
Home Phone*

Area CodePhone Number
Other Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Driver's License # (if adult)
Have you played guitar before, and, if so, how long?

YesNo# months# years
What are some of your favorite musical styles or bands?
Please write the name of any musical instruments you have had lessons for and for how long
Are you involved in any musical programs at school? If so, please explain.
What would you like to get out of guitar lessons - what is your goal?
What are 5 songs you would like to learn?
How would you rank your skill on the guitar?

BeginnerBeginner/IntermediateIntermediateAdvanced
NOTE: With younger children, (8 years old and younger) it would be very beneficial for the parent to attend the lessons with the child, at least initially. Though I do send out lesson summaries after each lesson, having the parent understand what is going on in the lessons will help the child practice at home. Please indicate below if you will or will not be able to do this.
Please give several Day/Time options for a lesson*
Parental Participation

Yes, I am to attend and participate in the lessons, at least initiallyNo, I am not able to attend and participate in the lessons
How did you find My Music Room?
Through*

Google/WebsiteCraigslistBackpageReferralReturn CustomerOther
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My Music Room Student Questionnaire

How did you find My Music Room?