Summer Private Lesson Registration Form
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First Name *
Last Name *
Date of Birth
MM
/
DD
/
YYYY
Age (or Adult) *
Parents/Guardians Name and Occupation (For Adult Students please list occupation) *
Street Address *
City *
Zip Code *
Primary Phone # *
Primary Phone Type *
Alternate Phone #
Alternate Phone Type
Clear selection
E-mail (please separate multiple e-mails with a comma): *
Primary Instrument Lesson Information
Instrument: *
Teacher:
Lesson Length:
Clear selection
Desired number of lesson (can add more at any point during the summer): *
Availability
Secondary Instrument Lesson Information
Second Instrument
Teacher
Lesson Length
Clear selection
Desired number of lessons:
Availability:
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. *
I certify that the information above is accurate to the best of my knowledge *
Required
I agree to pay the TOTAL DUE for the lessons registered above according to the payment policies of KSMA. *
Required
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