Talley Piano Studio

STUDENT NAME________________________________________________________________________________________BIRTHDATE____________________________________________________________

PARENT OR GUARDIAN NAME_______________________________________________________________________________________________________________________________________________

ADDRESS ______________________________________________________________________________________________________________________________________________________________________________________________

CITY_________________________________________________________________STATE_______________________________________________________________ZIP CODE_____________

PRIMARY PHONE_________________________________________________________________________CELL PHONE_______________________________________________________________________

EMAIL ADDRESS______________________________________________________________________________________________________________________________________________________________________________

PIANO OR MUSIC EXPERIENCE______YES__________NO_______ IF SO WHAT KIND___________________________________________________________

DO YOU OWN A PIANO OR KEYBOARD______YES___________NO_______________

DOES YOUR CHILD HAVE ALLERGIES______________________________________________________________________________________________________________________________

EMERGENCY CONTACT NUMBER_______________________________________________________________________________________________________________________________________

LESSON LENGTH - THIRTY MINUTES_________FORTY FIVE MINUTES__________SIXTY MINUTES_______________________

PLEASE COMPLETE THE ENROLLMENT FORM AND EMAIL TO THE STUDIO AT [email protected] or [email protected]. AS SOON AS IT IS RECEIVED THE STUDIO WILL CONTACT YOU TO ARRANGE A LESSON DAY AND TIME.

THANK YOU FOR CONSIDERING US FOR YOUR CHILD'S PIANO EDUCATION

PLEASE PRINT