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Summer Private Lesson Registration Form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age (or Adult)
*
Your answer
Student's pronouns (optional)
Your answer
Parents/Guardians Name and Occupation (For Adult Students please list occupation)
*
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Primary Phone #
*
Your answer
Primary Phone Type
*
Home
Cell
Work
Other:
Alternate Phone #
Your answer
Alternate Phone Type
Home
Cell
Work
Other:
Clear selection
E-mail (please separate multiple e-mails with a comma):
*
Your answer
Primary Instrument Lesson Information
Instrument:
*
Your answer
Teacher:
Your answer
Lesson Length:
30 minutes - $30/lesson
45 minutes - $45/lesson
60 minutes - $60/lesson
Other:
Clear selection
Desired number of lesson (can add more at any point during the summer):
*
Your answer
Availability
Your answer
Secondary Instrument Lesson Information
Second Instrument
Your answer
Teacher
Your answer
Lesson Length
30 minutes
45 minutes
60 minutes
Other:
Clear selection
Desired number of lessons:
Your answer
Availability:
Your answer
Information for KSMA Office
PHOTO/VIDEO RELEASE: I authorize photographs/ videos of the student identified above to be used solely for teaching and/or advertising for The Kanack School of Musical Artistry.
*
Yes
No
I certify that the information above is accurate to the best of my knowledge
*
Yes
Required
I agree to pay the TOTAL DUE for the lessons registered above according to the payment policies of KSMA.
*
Yes
Required
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