Confidential Enrollment Form

Email *

Today's Date *

First Name *

Last Name *

Phone *

Who are you enrolling? *

Myself

My Child(ren)

My Grandchild

For a Group

Which music lesson option are you enrolling? *

Piano Lessons

Voice Lessons - Child (10 & under)

Voice Lessons - Teen / Adult

Both Piano & Voice Lessons

Young Girls' Singing Club

Songwriting

Other:

How did you hear about us? *

Bark.com

Friend

Extended Family Member

Wilson Music Store

Yellow Sign

Google Search

Website

Other:

Has there been any prior music lessons/exposure? Please describe. *

Which mode of lesson do you prefer? *

In-person

Online

Video

All three when applicable.

What is your TIME ZONE?

Choose your 1st date to begin lessons. *

Choose a 2nd date to begin lessons. *

Is TEXTING okay? *

Yes

Type Phone? *

iPhone

Android

If you're enrolling for piano lessons, do you have access to an acoustic or electric piano? *

Yes

Maybe

I plan to purchase soon.

Can you provide LINK to options?

Not Applicable - NA

Please, ask any further questions you have below. *

Please note ENROLLMENT is not completed or scheduled lesson times confirmed until first month payment + supply fee have been received. You will have the opportunity to discuss payment options during your phone call with the teacher. *

I understand.

I have further questions.

SECTION TWO -
Student Information

Full Name *

Date of birth *

What school grade is your student in this year? *

Phone Number, if student has a phone. *

Student Email, if they have one. *

Does your student have an iPad or Tablet? *

iPad - personal

iPad - school

Tablet - personal

Does your student have any special challenges? This form is strictly confidential.

Reading

Math

Physical

Emotional

Behavorial

Autism

Asperger Syndrone

Fragile X

Dyslexia

Other:

Is your student involved in other activities such as sports, gymnastics, dancing, sketching/drawing, art classes, or local theater plays? If so, please share the approximate schedule for each. *

Please share which day/time of the week would work best for weekly music lessons and a daily practice schedule? *

Is there anything else you would like to share about your student that would help the music teacher customize their musical journey for the best possible experience?

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