Student Information ← BackThank you for your response. ✨ Today’s Date Student Name Address (Please, include city and zip code.) Date of Birth Grade School District Contact Parent’s Name Contact Parent’s Cell Phone Number Contact Parent’s Email Would you like this contact information included on the “Swap List”? This is a list published to those wishing to have the option to trade lesson times with another student, on occasion. Emergency contact name and number, in the event a parent cannot be reached. Do I have your permission to use your child’s image?(required) Have you read my Studio Policy, including the options available if a lesson will be missed? Please, list any allergies: Medications or medical issues that I should be aware of: How did you hear about me? Do you own a piano or a keyboard that is weighted and touch sensitive? Student’s Extra-Curricular Activities Musical Background of Student or Family Members SubmitSubmitting form Δ Share this: Share on X (Opens in new window) X Share on Facebook (Opens in new window) Facebook Like Loading...
June Kohlbeck Piano Studio 