New Student Registration Form

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Date of Entry

YYYY

Student's Name *

Birthdate *

YYYY

email address *

Address *

Cell Phone *

Phone number *

Parent/Guardian Name *

Parent /Guardian email address *

Were you referred by anyone? *

Prior Private Voice/Piano Instruction? (If Yes, how long?)
*

Choir Participation? Voice Part?
*

Soprano

Alto

Tenor

Bass

Do you read music?
*

Yes, very well

Yes, somewhat proficiently

No, not at all

Do you play any other instrument? *

Musical Influences? What genres, styles, artists inspire you?
*

What do you love most about singing or playing piano?
*

Please list School/Community performances (roles, recitals, concerts,etc.):
*

Repertoire: Please list titles/composers of solo pieces you have studied, performed, etc.
*

Goals: What do you wish to gain/improve from private voice/piano lessons?
*

Vocal Health Questions

Any past vocal injuries or surgeries?
*

Family vocal history of vocal injuries or surgeries?
*

Have you had any long term raspiness or laryngitis? If so, how frequently?
*

Are you a heavy voice user ( such as through work or sports)?
*

Any past non-vocal physical injuries, issues or surgeries that you feel may influence your singing that you wish to share with me ( ie deviated septum, TMJ, tonsillectomy, acid reflux, allergies, chronic pain, back, neck, shoulder surgery or anything else?)
*

Any epilepsy? If so how do you advise me to respond to help you should a seizure occur? ( this has occured during my decades of teaching)
*

Are you diabetic? If you have a low blood sugar incident during lessons how do you advise me to respond to help you? ( I have had students with diabetes become low blood sugar and I had orange juice ready to bring the sugar up. I do have family members who are diabetic.

Are there any cognitive and/or emotional issues that may be obstructive to pursuing or reaching your performance goals that you wish to share with me? ( i.e. confidence issues, stage fright, depression, anxiety, dyslexia, ADD, bi-polar disorder, OCD, scoliosis, back or neck surgery or anything else I should know about to help you better?
*

Did you ever struggle with any cognitive or/emotional issues affecting your musical pursuits that you have since overcome that you would like to share with me?

Medications may affect your voice, please list any medications you are currenty taking or take occasionally.
*

Have you taken yoga or do any yoga stretches or poses on your own to help with strengthening or relaxing your body and mind? ( it is helpful for singers.)

Questions / Additional Comments?
*

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