New Student Summer Registration

Choice 1: Day of Week for First Instrument *

Prior Experience and/or Goals:

Choice 2: Time-Frame for Second Instrument

Choice 1: Time-Frame for First Instrument *

Choice 1: Day of Week for Second Instrument

Primary Contact Name: *

Comments:

Comments/ Questions:

First Instrument: *

Address: *

Music 101 POLICY ACKNOWLEDGEMENT *

In checking this box, I (parent/guardian or adult student) understand the following Summer Lesson Policies: There are no make‑up lessons or refunds for student absences. Any missed time by the student due to tardiness will not be made‑up or refunded. If choosing in-person lessons, Music 101 reserves the right to send students home who fail to comply with safety policies. By signing, I am willing to comply with the established guidelines. Summer tuition is to be paid by cash or check in order to reserve the agreed upon lesson time.

Birthdate *

Teacher Preference for First Instrument:

SECOND INSTRUMENT:

Choice 2: Time-Frame for First Instrument *

Parent/ Guardian or Adult Signature *

Choice 2: Day of Week for Second Instrument

Email Address: *

Secondary Contact Phone Number:

Choice 2: Day of Week for First Instrument *

Lesson Length *

Teacher Preference for Second Instrument:

I give permission to Music 101 to photograph and audio/video record classes, lessons and other activities, to be used in print or electronic promotions. Music 101 will not publish the names of students without parental consent *

Secondary Contact Name:

Choice 1: Time-Frame for Second Instrument

Emergency Contact Name *

Primary Contact Phone Number: *

STUDENT NAME: *

Emergency Contact Phone Number: *

Lesson Length for Second Instrument

New Student summer registration