Student Full Name:

Parent/Guardian Full Name: (If Student is under 18)

Email:

Phone Number:

Street Address:

City/Town:

Student Age:

Student Gender: Select: Male Female

Student Occupation/School:

Preferred Lesson Time: Select One: Weekday afternoons (3pm-5pm) Weekday evenings (5pm-8pm)

Lesson Interest: Select One: Piano Lessons Violin Lessons

I have taken lessons for: Select One: No Prior Lessons Less than 6 months More than 6 months More than 1 year

How did you hear about Ebony and Ivory Music Studio? Select One: School Music Teacher Recommendation/Word of Mouth Yelp Google Other If Other Referral, Please Specify:

What is your Desired Lesson Length? Select One: 30 Minutes 45 Minutes 1 Hour

Why are you interested in private lessons?

What are your musical goals?

Please rate your note-reading ability: Select One: Nonexistent Beginner Pretty good Strong Above average

Please list any musical instruments played, indicating whether you had private lessons:

Additional information about yourself: