Lesson Registration Form Today's Date * MM DD YYYY Student Name * First Name Last Name Student's Birthdate * MM DD YYYY Lesson Type * SUMMER ONLY CLASSES Piano Guitar Voice Drums Steel Drums Bass Ukulele Trumpet Trombone Saxophone Flute Art Lesson Style * Private Semi-Private Group Name of Person Responsible for Tuition * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Parent/Legal Guardian * Is the Person Responsible for Tuition also the Parent/Legal Guardian? Yes No Emergency Contact Name * First Name Last Name Relation to Student * Phone * (###) ### #### How did you hear about us? * Tuition Billing * Check below if you want your monthly tuition to be automatically billed (this will require a signature on file) Yes No Special Requests If you need a specific day of the week/time, please mention it here. We try our best to coordinate your schedule with our instructor's schedules, but cannot guarantee all requests will be met. Thank you for submitting your registration form! Someone will reach out to you shortly regarding scheduling. In the mean time, if you have any questions, please call us at 740-264-3111.
