Piano Sensei Enrollment

Enrollment Form
Your Name

First NameLast Name
Email
example@example.com
Home Phone
Format: 000-000-0000.
Mobile Phone
Format: 000-000-0000.
Other Phone
Format: 000-000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you enrolling for yourself or a child?
Type
Birth Date

MonthDayYear
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
How did you hear about us?

Other
Who referred you?
Do you have an instrument already?
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.

Rows	9:00am-11:00am	11:00am-1:00pm	1:00pm-3:00pm	3:00pm-5:00pm	none
Saturdays
Sundays

Scheduling Comments
Weekly lesson length preference:
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