Student Name *

First Name

Last Name

Student Birthdate *

MM

DD

YYYY

Guardian Name (If applicable) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What are you interested in? *

Can choose more than one

Private Violin Lessons

Private Piano Lessons

Trial Lesson (First Time Newcomer Only)

Music Garden for Tots (Ages 2-3)

Music Garden for PreK (Ages 3-5)

What day works best for you? *

Can choose more than one

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Do you give The Good Music Academy permission to use photos and videos of your student on social media platforms? *

Yes

No