First Name

Last Name

Birth date

Mother’s Name

Father’s Name

Street Address

City

State

Zip Code

Home Phone Number

Mother’s Work Number

Father’s Work Number

Cell Phone

E-Mail

Fax Number

Other

Instrumental Lesson #1

Length of Lesson

Instrumental Lesson #2

Length of Lesson

Music Theory & Ear Training

History of Western Music

Location

Preferred Day and Time for Lessons

Signature of Parent

Date