Student Application for Piano Lessons

(Please print form and mail to me by regular mail or copy and paste into email. Email me for mailing address and location information)

Student Information

Full Name: ______________________________________ Age: ________________

Amount of previous music training: _________________ Type: ________________

Email: _______________________________________________________________

Why do you want to take lessons? _________________________________________

_____________________________________________________________________

What I have to practice on:(circle one) Piano Keyboard I need to get something

Is this at your home? _______ If not, where? _______________________________

Desired Lesson times: 1^st Choice _______________ 2^nd Choice _____________

When will you start lessons? ______________________________________________

Name: _______________________________________________________________

Full Address: __________________________________________________________

Home Phone: _______________________ Other phone: _____________________

Email: ________________________ Best way & time to contact you: ____________

What type of music background does either parent have? ______________________

Will either parent be available to help during practice times? Yes No

Signature of Parent/Guardian _____________________________ Date: ___________