New Student Registration Form

Student Name

Date of Birth

Contact Parent’s Name

Contact Parent’s Cell Phone Number

Contact Parent’s Email

Emergency Contact Name and Number (In the event a parent cannot be reached).

Do you give permission to share contact information with other students/parents for lesson swaps?(required)

Yes No

Please specify the type of piano or weighted and touch-sensitive keyboard that you have at home:

Student’s Extra-Curricular Activities

Please list any allergies:

Medical conditions, medications, or learning needs I should be aware of:

Media Release: Do I have your permission to use photos or videos of your child for studio promotional materials?(required)

Yes No

Studio Policy Acknowledgment: Have you read and agreed to the Studio Policy (including cancellation and makeup options)?(required)

Yes No