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