Student's Name

My Best Contact

Email Address

Phone Number

Student's Grade Student's Grade 2nd 3th 4th 5th 6th Other

Adult Age Adult Age 20 30 40 50 Other

Senior Age Senior Age 60 70 80 90 Other

I Am Interested In I Am Interested In Day Classes After School Both Adult|Senior

Have You Had A Music Lesson Before? Have You Had A Music Lesson Before? Yes No

Instrument | Date

Do I Have A Piano At Home? Do I Have A Piano At Home? Yes No

Besides Piano, What Else Would I Like To Discover: Besides Piano, What Else Would I Like To Discover: Pick all that apply Drums Guitar Voice/Rap Dance Public speaking Comedy Theater All of the above

Who Else, In My Family, Is Musical? Who Else, In My Family, Is Musical? Pick all that apply MOM DAD G-PARENT BEST FRIEND

My Music Goals: My Music Goals: Pick all that apply PERFORM FOR OTHERS BRING PEOPLE TOGETHER TO PARTICIPATE ENJOY QUIET TIME SURPRISE A LOVED ONE FOR AN EVENT GAIN CONFIDENCE DEVELOMENT INTEREST BECOME A ROCK STAR

My Other Activities Are: My Other Activities Are: Pick all that apply Dance/Karate Gymnastics Sports such as: Baseball, Swimming, Football, Basketball, Tennis Horseback riding Motocross Photography Babysitting Writing / Author Sewing Gardening Crafts Reading