Students Name:

Male

Female

Age

Parents Name (if student is a minor):

Address:

City:    State:     Zip Code:

Email:

Phone Numbers:

Home:   Cellular:

Work: (Check main contact number)

Enrollment Information

Instrument?:

Instructor Preference:

Prefrerred Days & Times:

Is Student a Beginner? Yes No

If no, explain how long students has played/studied the instruments

Is the student part of a band, orchestra or ensemble Yes No

To help us effectively place the student with an instructor list the musical genres the student is interested in:

In signing this form, I certify that all information provided is complete and true.

Signature:                     Date:


Printed Name:

Ethnic background (optional):
White    Black     Hispanic     Native American   Asian     other: