Confidential Enrollment Form

Enter Access Password

Request Access

Incorrect password. Please try again.

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

Familial Sex Abuse

Trafficking - (Labor or Sex)

Other: Please share in last box below.

No known issues to date.

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?

Home
Inquire
Get Started Now!

Facebook

Instagram

Youtube