Private Lesson Registration Form
For private music and art lessons
Student's Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Type of lesson student is registering for *
Parent/Guardian's Name (if under 18)
Your answer
Email *
Your answer
Street Address *
Your answer
Town/City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone # to be reached at on day of lessons *
Your answer
Secondary Phone
Your answer
Please list any allergies (write N/A if none) *
Your answer
Will the student have an epi-pen in lessons? *
Primary Care Physician
Your answer
PCP's phone #
Your answer
Emergency Contact Name (in addition to the parent/guardian listed above) *
Your answer
Emergency Contact Relation *
Your answer
Emergency Contact Phone # *
Your answer
Permission to be photographed *
At times we may take pictures during lessons for our website, professional facebook page, and/or other promotional materials (brochures, pamphlets, newspaper articles, etc.). Please check below to give permission or decline permission to photograph the student for the previously mentioned reasons.
Permission to be recorded *
At times we may take video during lessons for our website, professional facebook page, presentations, and/or other promotional materials. Please check below to give permission or decline permission for us to record the student for the previously mentioned reasons.
Medical Attention *
In the event of an emergency requiring medical attention, I understand that Sing Explore Create, LLC will make every effort to contact and notify the listed parent/guardian and emergency contact listed above. However, if neither can be reached Sing Explore Create, LLC reserves the right to call emergency personnel to transport the student to the nearest medical facility to secure necessary medical treatment.
Pick Up Policy
For students under age 18, we reserve the right to ask for picture identification from anyone picking up students from Sing Explore Create, LLC studios. Only those who have been given written permission from the students' parent/guardian will be allowed to pick up. PLEASE LIST THE NAMES OF THOSE WHO MAY BE PICKING UP THE STUDENT BELOW. In the event that a student music be picked up from lessons by someone not listed below, hand-written notification and permission from the parent/guardian music be given to the teacher prior to the student being dismissed.
Your answer
Accomodations
We strive to create an environment in which all students feel comfortable getting creative and have a successful lesson experience. Please let us know of any special accommodations the student may need. Describe below, or write "call me" and a teacher will contact you for more information.
Your answer
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