Private Lessons & Songwriting Registration Form
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BASIC INFORMATION
STUDENT'S FIRST NAME *
STUDENT'S LAST NAME *
STUDENT'S DATE OF BIRTH *
MM
/
DD
/
YYYY
STUDENT'S AGE *
STUDENT'S GENDER PRONOUNS
ADDRESS *
SCHOOL/GRADE *
NAME OF PARENT(S)/GUARDIAN(S) *
PARENT/GUARDIAN EMAIL 1 *
PARENT/GUARDIAN EMAIL 2
PARENT/GUARDIAN CELL PHONE 1 *
PARENT/GUARDIAN CELL PHONE 2
STUDENT'S CELL PHONE
EMERGENCY CONTACT NAME/NUMBER *
RELATIONSHIP TO STUDENT *
Does your child have permission to leave the studio on their own, without adult supervision? *
Does your child have any allergies? *
If yes, please explain:
Are there any other medical issues or other information we should know about your child? If yes, please explain:
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