Student Intake Form

Complete this form before your first lesson.

Student's First Name

Student's Last Name

Student's Birthday

Preferred Phone Number

Select an Address

Parent/Guardian Name (First and Last)

What is your musical background? (Do you read music? What instruments have you played? Been in a band or choir?)

What do you want to accomplish from these lessons?

Are there any health concerns or learning issues I should know about?

Please tell me anything else about yourself you would like me as your teacher to know.

How did you hear about me?

I found you online searching for music lessons

Social Media

A friend told me about you

I saw your flyer/poster

Piano by Marcia has my permission to use my photograph/video publically to promote the studio. I understand that the images may be used in the print brochure, website, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Yes

I agree to the terms & conditionsView terms of use

Thank you for registering! Please allow 2-3 business days for a response.