Piano Lesson Registration Form

Due to inconsistencies in web technology, emails occasionally don’t reach us. If you don’t get a reply to your registration within two days, call or text us at 952-322-4329.

A REGISTRATION FEE PAYMENT OF $40 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’S NAME”, etc..

EMAIL(required)

STUDENT'S FIRST AND LAST NAME(required)

HOW DID YOU HEAR ABOUT US?

ENTER THE NAME OF THE REFERRAL SOURCE CHOSEN ABOVE

DATE

ADDRESS

CITY

ZIP

STUDENT DATE OF BIRTH

PARENT'S FIRST AND LAST NAME

PHONE #1

PHONE #2

STYLES OF MUSIC YOU WANT TO LEARN (Pop, Classical, Jazz, Blues, etc.)

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 PROSPECTIVE STUDENT IS ATTENDING, AND THEIR TEACHER'S NAME

BRAND, MODEL #, AND YEAR OF THE KEYBOARD INSTRUMENT YOU OWN

Choose one Acoustic Piano

Digital Piano (with built in stand or cabinet)

Portable Electronic Keyboard (with separate stand, e.g. "X" stand)

Toy Piano (keys smaller than standard)

DO YOU NEED ADVICE IN SHOPPING FOR A KEYBOARD INSTRUMENT?

PREVIOUS MUSIC TEACHER'S NAME AND YEARS OF STUDY

DID YOU ACHIEVE YOUR MUSIC LESSON GOALS? Yes

WHY DID YOU STOP TAKING LESSONS FROM THIS TEACHER?

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.

DESCRIBE ANY FOOD ALLERGIES THE STUDENT HAS

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