Name of Student ______________________________
Age _________ Birthday ________________________
Grade ___________________ School ___________________________________
Has the student had any previous piano instruction? If yes, which book(s) / method?
__________________________________________
How many months / years of study? _____________________
Preferred Session for Blast Off With Piano ©
I-July 14-18 _________ II-July 21-25 ________
Parent Information
Name ___________________________________________
Address _________________________________________
City _____________________ State _____ Zip __________
Phone ___________________ Parent's email _________________________ (For studio use only)
Class Registration
_____ Summer 2003 Blast Off With Piano
_____ Fall 2003 Group Piano Lessons begin the week of August 11
_____ Spring Semester 2004 Group Piano Lessons