Private Lessons & Songwriting Registration Form

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Have questions or need help completing your form? Email us at info@replaymusicschool.com

BASIC INFORMATION

What semester are you signing up for? *

Fall

Winter/Spring

Both the Fall and Winter/Spring Semesters

STUDENT'S FIRST NAME *

STUDENT'S LAST NAME *

STUDENT'S DATE OF BIRTH *

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 *

Parent/Guardian

Family Member

Caretaker/Nanny

Other:

Does your child have permission to leave the studio on their own, without adult supervision? *

Yes

Does your child have any allergies? *

Yes

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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