Music Classes Application

*(denotes required field)

Child's First Name *

Child's M.I.

Child's Last Name *

Parent's First Name *

Parent's M.I.

Parent's Last Name

Home Street Address *

City *

State *

Zip *

Home Telephone

Cell

Work Telephone *

Email *

Child's School *

Music Teacher

Grade in School

Birthday *

Does your child receive free lunch at school? *

Yes
No

NOTE: Students' success hinges on parents' encouragement and interest in their child's learning and personal growth. A commitment to consistent Saturday attendance is key to this. Additional field trips (i.e. concerts and performances) will be a part of this program. Continuation in the music program is based on consistent, weekly attendance, behavior, and satisfactory growth within the program. I give permission to use my child's name, photograph and/or performance recordings (including audio an/or video forms) in brochure, web, and other promotional materials.

COST: A 55-minute private, instrument lesson plus 55-minute music theory session equals a $50, discounted value each week. Please indicate below: (1) an amount, from $25 to $50, that you can afford each week and (2) helpful comments, if warranted, that support your need. We reserve the right to request copies of most recent tax-filing forms to support need. Your information is strictly confidential.
AMOUNT: *

Parent/Guardian Digital Signature *

Date

Select the one instrument that you would like to study:

Violin
Viola
Cello
Bass
Piano
Guitar
Voice
Drums

If the instrument you would like to study is not on the above list, what is that instrument?

Do you have access to your choice instrument for consistent lessons and practice?

Yes
No

Do you currently take lessons on an instrument?

Yes
No

If yes, what is that instrument?

How long have you had lessons on your instrument?

Who is your teacher?

List all music classes and lessons you have had and for how long. *

Write up to five lines that tell why you want to participate in this program and what you would like to do with music. Dream big! *

CAPTCHA Code: *