Student Information

Student Name (required)

Student Date of Birth (required)

Parent Name (if student < 18 years old)

Student's (or Parent's) Email (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Phone Number 1 (required)

Phone Number 1 (required) is:
 Home Cell Work

Phone Number 2

Phone Number 2 is:
 Home Cell Work

Phone Number 3

Phone Number 3 is:
 Home Cell Work

Instrument Information and Previous Experience

Select the instrument to be studied:
PianoGuitarTrumpetFluteClarinetSaxTromboneFrench HornTubaViolinViolaCelloString BassElectric BassDrumsMusic CompositionVoiceOther

Is the student a beginner?  Yes No

If no, then please briefly describe previous experience:

Select the preferred instructor:
No PreferenceKevin RoseSaid TinatSven RaineyDr. Jon CresciTina SmithYoshiaki HoriguchiDr. Joscelyn FisherSimeone TartaglioneNicole SheelerVirginia MorganValerie HarveyScott D. FarquharDon't Know / Please Advise

Please select the student's level of interest and commitment to practice:
Trial: 15-30 Minutes, 3 times per weekVery Light: 15-30 Minutes, 5 times per weekLight: 15-30 Minutes, every dayCasual: 30-60 Minutes, every daySerious: 1-2 Hours, every dayDevoted: 2+ Hours, every day

Student Availability

Note about scheduling - The more options you can provide for your availability, the easier it will be to match you with a teacher. Please provide a minimum of 2 days with a 2-3 hour window on each day.

Indicate a preferred lesson length (Some ages, instruments, and teachers have a 45-Minute minimum):
 60 Minute 45 Minute 30 Minute

Indicate which days the student can have a lesson (must choose at least one)
 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Please fill in a time range for each day the student is available for a lesson (i.e. start at 3pm - end by 7pm)

Sunday Times:
Monday Times:
Tuesday Times:
Wednesday Times:
Thursday Times:
Friday Times:
Saturday Times:

Please indicate any other activities the student is engaged in which may have an impact on scheduling and practice time between lessons:

Other Student Information

Does the student have any special needs?
 Yes No

If so, please describe:

Please indicate any specific goals or motivation for wanting music lessons:

Please indicate any special offer you are responding to:

Please let us know how you heard about us: