Student Name: Age: Birthdate: Parent/Guardian Name: Home Phone: Work Phone: eMail: Mailing Address: , NY Home Address: (if different from mailing address) , NY Instrument: ---TrumpetGuitarBassother Desired Lesson Time: ---SundayMondayTuesdayWednesdayThursday AMPM Has the student previously taken private music lessons? NoYes If so, for how long? Does the student play in any school or community groups? NoYes If so, which ones: Does the student play any other instruments? NoYes If so, which ones: Any additional notes or comments? Please read our Lesson Policy before submitting this form. Please fill out the Captcha before submitting