Harmanny Music Education Fall Sign Up Form
Please fill in the answers below
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Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Grade (if adult or preschooler, leave blank)
School (If adult or preschooler, leave blank)
Student's birthday (don't need to put the year if you don't want!) *
Mother's Name (if adult student, leave blank)
Father's Name (if adult student, leave blank)
Phone *
(Parent) Email address *
Mailing address *
Preferred method of contact (in case of cancellation) *
Emergency Contact (If parent cannot be reached) *
What is your preference for day of the week for your lesson? *
What is your time preference for your lesson, if after school hours? Friday lessons only available between 3:30-5
3:30-4
4-4:30
4:30-5
5-5:30
5:30-6
6-6:30 (only Monday)
6:30-7 (only Monday)
1st choice
2nd choice
3rd choice
Clear selection
What is your time preference for your lesson, if during the day? (Only for adults, homeschool students or non school age children)
10-10:30
10:30-11
11-11:30
11:30-12
1-1:30
1:30-2
2-2:30
2:30-3
3-3:30
1st choice
2nd choice
3rd choice
Clear selection
Other Extracurricular Activities *
Does either parent (or students) have musical training? If so, what instrument and how many years?
Other children? (Names and ages) *
What are the goals for music education? *
Does student have access to instrument for practice at home? *
Does the student have any unique attributes, physical or learning challenges that may affect their ability to learn music? If so, what are they? *
How much time can your child commit to practice each day (Recommended 15 min/day x 5 days for prep, 20 min/day x 5 days for Beginner, 30-60 min/day x 5 for Intermediate *
Is the student interested in composing music? *
If you were referred by a current student, who referred you?
Harmanny Music Education has permission to use my child’s (under 18) likeness on social media (Harmanny Music Education website, Facebook/Instagram/Twitter) *
I have received and agree to follow all of the policies set out by Harmanny Music Education for fall 2021 lessons. *
I give permission for Harmanny Music Education to autodraft monthly tuition installments from my debit/credit card on file through Square
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