Piano Sensei Enrollment

Enrollment Form
Your Name*

First NameLast Name
Email*
example@example.com
Home Phone*
Mobile Phone*
Other Phone
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MyselfChild (under 18)
AdultParent
Birth Date*

MonthDayYear
Birth Date*

MonthDayYear
Date
Student Name*

First NameLast Name
Student Email (IF they have one)
example@example.com
Student phone (IF they have one)

Area CodePhone Number
School*
Grade in School*
Special needs, learning difficulties, and/or allergy information
Web searchThumbtackDrove by/Saw signReferred by someoneOther
Who referred you?*
YesNo
What kind? (acoustic, electric, brand, etc)*
Musical background (if any)
Hobbies/interests/extra-curricular activities
Does anyone else in your household play piano or other musical instruments?
Scheduling Preferences

Please mark the times you're available for each of the following days or check "none" if not available on that day. Please mark ALL possible options as these will be used to schedule periodic group classes as well as your weekly private lesson.

Scheduling Comments
30 minutes (for young beginners 8 and under)45 minutes60 minutes75 minutes90 minutes (for advanced students age 16 and up)not sure
Policies & Procedures

Please read (you can also zoom in or download the document) and then sign below.
Sign here to acknowledge you read, understand, and agree to the policies and procedures above.*
MEDIA RELEASE: I hereby grant permission for Clinton Pratt and/or PianoSensei to use photographic images and/or audio recordings and/or video recordings of myself, inprint, electronic media, or online media for promotional, educational, and other lawful purposes without compensation. I agree to waive and release any and all claims I may have against Clinton Pratt and/or Piano Sensei relating to the use of these recordings or images. This consent is binding upon heirs and future legal representatives. *
MEDIA RELEASE: I hereby grant permission for Clinton Pratt and/or Piano Sensei to use photographic images and/or audio recordings and/or video recordings of "student" mentioned above, in print, electronic media, or online media for promotional, educational, and other lawful purposes without compensation. I understand that either first name only or no name at all will be used. I agree to waive and release any and all claims I may have against Clinton Pratt and/or Piano Sensei relating to the use of these recordings or images. This consent is binding upon heirs and future legal representatives. *
Should be Empty:

Enrollment Form