Music Lesson Registration Form printable pdf download

2016-2017 MUSIC LESSON REGISTRATION FORM

Student Name

Today’s date

(Last name)

(First name)

Date of Birth

Grade

(as of Fall 2016)

Name of Parent or Caregiver

Email _______________________________________________

Address _____________________________________________________________________________________________________________________ ______

(

(Street)

City)

(Zip)

Primary Number (who) ___________________________________________ Secondary Number (who) ___________________________________________

How many years have you taken lessons?

__________________

Does your child have any special needs of which we should be aware?



Yes

(If “yes”, describe on the back, including any suggestions for how we may best help and support.)

Scheduling





Type of Lesson: 30 minute Private

(Select One)

PIANO

FLUTE

GUITAR

PIANO

CLARINET

VIOLA

VIOLIN

VOICE

Days You Are Available:

Time of Day Preference:

Location:

 Miss Jessica at First Presbyterian Church Miss Anne at First Presbyterian Church

Payment Information

 Visa  AMEX  MasterCard 

iscover

Automated Monthly Credit Card/Debit Card Payment -$115 (1 month down + October 2016-May 2017)

Card #

Exp

Security Code

Name as it appears on card

Automated Monthly Deduction from Savings/Checking Acct:

 SAVINGS

 CHECKING

Name on Account:

Bank Routing #:

Bank Acct#:

NOTE: 60-Day Notice required for withdrawal mid-term. Fee will be charged on the 1

of each month

Instrument Information

Having an educationally appropriate instrument on which to practice is critical to a successful lesson experience. Please help us learn

a little more about the instrument(s) you have at home.

What instrument(s) do you have at home?



Acoustic Piano

Digital Piano

Keyboard

Organ

Violin

Viola

Cello

Flute

Oboe

Guitar

Ukelele

What brand is your piano or keyboard?

Approximate age of piano or keyboard?

What size is your violin (if you have one)? ¼, ½, ¾, Full

Signed ________________________________________________________ Date _______________________________

Please return to: Musical Pathways Foundation, 5579 Easy Street, Waunakee WI 53597

musicalpathways.net, (608) 576-6688

Music Lesson Registration Form

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