Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Name *

First Name

Last Name

Student School

First Name

Last Name

Student Class

First Name

Last Name

Instrument/Discipline *

Keyboard

Guitar

Ukulele

Electric Bass

Lesson Type *

Individual, Paired or Group (please note, Paired and Group lessons are not offered in all schools, please contact if unsure)

Individual Lessons

Paired Lessons

Group Lessons (3/4 Students)