Student Name:

Age: Birthdate:

Parent/Guardian Name:

Home Phone:

Work Phone:

Cell Phone:

eMail:

Mailing Address:

, NY

Instrument: ---TrumpetGuitarBassother

Desired Lesson Time: ---SundayMondayTuesdayWednesdayThursday AMPM

Lesson Length: ---Half-HourOne-HourOther

How did you hear about the New York Music School? ---Another SudentCraigslist AdFacebookSearch Engine (google, yahoo, etc.)Other

Has the student previously taken private music lessons? NoYes
If so, for how long?

Does the student play in any school or community groups? NoYes
If so, which ones:

Does the student play any other instruments? NoYes
If so, which ones:

Any additional notes or comments?

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