Lesson Registration - That Music Place

Name of Person Completing Form*

First Last

Relationship to Student

Email*

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Name

First Last

Student Date of Birth

Days/Times Student is Available

Lesson Type (which Instrument do you want to learn?)*

Preferred Style

Style of music or style of playing interested in learning if have a preference.

Instrument Rental

Student has an intrument
Student needs to rent an intrument

List Any Previous Musical Lessons or Experience

Name of School

Does the Student have any Special Needs?

Such as wheelchair access, vision or hearing assistance, etc.

General

Please include any other information that would be helpful for the teacher.

Please only submit once. Form does send even if it does not resolve on your end. Someone will contact you once your form has been reviewed. Thank you.

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