Date

Parent(s) Name

Address  City/State/Zip
Home Phone Cell Phone    FAX 
Email address

Student Age Instrument
Student Age Instrument
Student Age Instrument

Select from one of the four choices below, then fill in appropriate information:

Yes, I'm continuing music lessons with the same teacher at the same time & day.

Teacher: Day(s): Time.

Yes, I'm continuing lessons but I would like to change the day to  ,   and/or  

              time to    and/or teacher     (list preferences in  boxes).                                                    

No, I'm not continuing lessons at this time.
Please call me.                      

Please write "yes"  in the box if you are paying registration fee by check
 

Additional Comments