Student Registration

Before filling out the form, please read the Studio Policies.

Student Name

Date of Birth

Mailing Address

Parent/Gaurdian's Name(s)

Home/Work/Cell Phone Numbers and best time of contact

Email Address

Student's current school and grade level

Please list the instruments the student enjoys and whether or not you have these at home

Does anyone else in your household play these instruments?

Please describe the type of music the student enjoys (i.e. pop, Disney, classical, rock, etc.)

Please list some activities/items that your student finds motivating or reinforcing

Please list any other information you would like me to know about your student

If possible, please attach a copy of your child's IEP. You do not need to make an extra copy; I will return these documents to you. If an IEP is not available, please list any identified goals that your student is working towards in school (such as increasing specific cognitive, motor, behavioral or social skills):

Are there other goals you would like me to work on with your student?

By checking this box I acknowledge that I have read and understand the Studio Policies.

This information will remain strictly confidential.
Thank you for taking the time to complete this page.