Guitar Lesson Registration Form

PLEASE NOTE: A REGISTRATION FEE PAYMENT OF $55 IS DUE WHEN A PERMANENT LESSON SLOT IS ASSIGNED TO THE STUDENT.

ALL RELEVANT FIELDS MUST BE FILLED IN ORDER FOR A REGISTRATION TO BE ACCEPTED.

Adults can skip fields such as “SCHOOL NAME…”, “PARENT NAME”, etc..

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GUITAR STUDENT’S FIRST AND LAST NAME

STUDENT DATE OF BIRTH

PARENT’S FIRST AND LAST NAME

ADDRESS

CITY

ZIP

PHONE #1

PHONE #2

HOW DID YOU HEAR ABOUT US?

ENTER THE NAME OF THE REFERRAL SOURCE CHOSEN ABOVE

STYLE OF MUSIC THE STUDENT WANTS TO LEARN; Select one

LIST AT LEAST THREE (3) LESSON DAY/TIME SLOTS THAT FIT YOUR SCHEDULE

LESSON DAY/TIME 1

LESSON DAY/TIME 2

LESSON DAY/TIME 3

SCHOOL NAME &; GRADE THAT THE PROSPECTIVE STUDENT IS ATTENDING, AND THEIR TEACHER’S NAME (N/A for Adults)

BRAND, MODEL #, AND YEAR (OR APPROXIMATE AGE) OF THE GUITAR YOU OWN

PREVIOUS MUSIC TEACHER’S NAME AND YEARS OF STUDY

IF THE STUDENT’S PARENTS HAVE DUAL CUSTODY, PLEASE ENTER THE NAME ADDRESS, AND PHONE NUMBERS OF THE ALTERNATE PARENT

ALTERNATE PARENT NAME

ALTERNATE PARENT ADDRESS

ALTERNATE PARENT CELL/WORK/HOME PHONE NUMBERS

DESCRIBE ANY INJURY/IMPAIRMENT, HAND-RELATED SURGERY/TREATMENT OR OTHER FACTOR THAT WOULD LIMIT THE STUDENT’S ABILITY TO PLAY THE PIANO, OR INTRODUCE PAIN WHILE DOING SO.

DESCRIBE ANY DIAGNOSIS OF ANY LEARNING DISABILITY OR MENTAL CONDITION THE STUDENT HAS.

Note: You must click the Send button below in order for us to receive your registration.

Due to e-mail delivery issues beyond our control, registrations occasionally don’t reach us. If you don’t receive a reply to your registration within two days, please call or text us at 952-322-4329.

Thank you for your response. ✨

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