Student Name *

Gender

Male Female

Student Birth Date *

How old is the student? *

What instrument is the student interested in studying? *

School Name *

Does the student have prior experience? *

Yes No

If so, how long has he/she been playing?

Student’s special needs
(physical, mental, behavioral or emotional health needs; learning modifications)

Does the student have any allergies?

Does the student take any medication?

Medication reason?

Hospital of preference?

What days do you prefer?

Monday Tuesday Wednesday Thursday Friday

What time(s) of the day(s) do you prefer? *

Are there any times/days that you absolutely cannot consider for lessons? *

What lesson length do you prefer? *

30 Minutes 45 Minutes 60 Minutes

What is your satellite location preference? *

Do you have a preference in instruction type? *

When would you like to begin lessons? *

Spring Summer Fall As soon as possible

Contact’s First Name *

Contact’s Last Name *

Contact’s Email Address *

Contact’s Phone

Street Address *

Street Address 2

City *

State *

ZIP Code *

How did you hear about Arts+?

Could the student be photographed or filmed for promotional materials, including Facebook, the Arts+ website, flyers and emails?

Yes No

Private Music Lessons

Student Information