Parents First Name*:
Parents Last Name*:
Email Address*:
Cell Phone Number*:
Home Phone Number:
Preferred Method of Contact (1st, 2nd, 3rd) text/phone/e-mail*:
Student First Name*:
Student Last Name*:
Student Email:
Student Phone:
Student Age*:
Student DOB*:
How did you hear about us?*:
New to piano?*:
If no: what is your reason for changing teachers:
What kind of piano do you have at home:*:
What extra curricular or hobbies do you participate in?*:
Are there any learning issues that I should be aware of? (explain)*:
Any additional information that would be helpful regarding learning piano:
Photo release: Does the instructor have permission to feature photos of this student (never using full last name) on the website, Facebook page and/or promotional items:
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