Lesson Enrollment Form-USE FOR LESSON ONLY-Under 18
ENROLLMENT FORMS FOR LESSON STUDENTS WHO DO NOT TAKE PERFORMANCE BAND
Enrollment Date: *
(Start Date)
Your answer
USER NAME FOR TEACHER ZONE *
(WE WILL ASSIGN)
Your answer
TEACHER ZONE PASSWORD *
(WE WILL ASSIGN-But you may change on first log in)
Your answer
STUDENT INFORMATION
Name: *
(student)
Your answer
Date of Birth *
Your answer
Current Address: *
Your answer
City: *
Your answer
State: *
Zip Code *
Your answer
CONTACT PHONE NUMBER -For Adult or Teen Students *
(BEST CONTACT)
Your answer
EMAIL ADDRESS- (if student is Adult or Teen)
Your answer
What is/are your goal(s) in lessons?
Your answer
PARENT / GUARDIAN INFORMATION
ADULT STUDENTS DISREGARD ALL PARENT INFORMATION
NAME: *
Your answer
ADDRESS: *
Your answer
City: *
Your answer
STATE *
CONTACT PHONE NUMBER *
(BEST CONTACT)
Your answer
SECONDARY CONTACT NUMBER
Your answer
EMAIL ADDRESS
Your answer
FACEBOOK? *
(WE USE FACEBOOK TO ANNOUNCE SHOWS AND SCHEDULE CHANGES)
PARENT / GUARDIAN INFORMATION
NAME:
Your answer
ADDRESS:
Your answer
STATE
CONTACT PHONE NUMBER
(BEST CONTACT)
Your answer
SECONDARY CONTACT NUMBER
Your answer
EMAIL ADDRESS
Your answer
FACEBOOK?
(WE USE FACEBOOK TO ANNOUNCE SHOWS AND SCHEDULE CHANGES)
What School does the Student attend?
(optional-used only for statistic purposes)
Your answer
Students Grade Level (current year or next session if summer enrollment)
(current year or next session if summer enrollment)
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Relationship to Student *
Your answer
IMPORTANT INFORMATION ON MUSIC INTEREST AND EXPERIENCE
Instrument(s) Student will be Learning *
check all that apply
Required
Students Current Skill Level or Expereince *
(do your best, we won't hold you to it)
Required
Students Music Interest *
(select all that apply)
Required
For Students 7 to 17 (or 18 but still in High School)
Are you interested in Performing on Stage in a Live Band?
Your answer
PAYMENTS
For Lesson Only Students How Do You Prefer to Pay? *
(does not apply to Performance Band Students)
ADDITIONAL INFORMATION
Is there anything we should know? Allergies/Medical Needs/Special Needs? Special Music or Instrument Request?
Your answer
If there were an Emergency do you have a preferred Hospital/Physician/Instructions?
Your answer
EAR PLUG WARNING AND WAIVER
Anyone exposed to amplified music and drum music should wear hearing protection at all times. This is especially important for children. *
We have earplugs available at the front desk at all times, some students prefer to wear ear muffs or headphones and they must be supplied by student.
Required
SIGNATURES
Signature of Applicant (parent or guardian for students under 18) *
Please Sign and Date
Your answer
Want to Attend for Free? We offer a 25.00 per month tuition credit for any student that brings a student to our performance band program for as long as the referral is enrolled in the program.
*offer doesn't apply to scholarship program students
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