Prospective Student Registration Form
Thank you for your interest in Resonance: Mind-Body-Music, LLC! All classes and lessons are held at 112 N. Main Street, Pearl River, New York inside Good Shepherd Lutheran Church. All levels and backgrounds are welcome!
Please fill out the following registration form. Thank you!
* Required
Student's Name
*
Your answer
Parent/Guardian Name(s)
*
Your answer
Student's Birthdate
*
Your answer
Student's Grade
*
Your answer
Best Cell Number
*
Your answer
Alternate Phone Number
Your answer
Email to correspond with Dr. Burns
*
Your answer
Email where invoice should be sent (if different from above)
Your answer
Student's interests
*
Your answer
How did you hear about Resonance: Mind-Body-Music? Referred by?
Your answer
I am interested in: (please check all that apply)
*
Private Lessons (Dr. Burns and one student)
Partner Lessons (Dr. Burns and two students)
Group Lessons (Dr. Burns and three or more students)
Required
Please describe your musical background, if any.
*
Your answer
Do you have a piano at home? If so, what kind? (No piano at home/Digital piano/Upright piano/Grand piano)
*
Your answer
Can you commit to spending time at the piano with your child each day?
*
Yes
No
Any other comments that might help me as I prepare lessons for your child?
Your answer
Media Release: Resonance students are often featured on social media, on our studio website, and in posters and brochures. Photos and videos may be taken at lessons, at studio events, and at recitals throughout the year. Do we have your permission to post photos/videos of your child? Names are not used in these posts.
*
Yes
No
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
