New Student Form

Tue, 11/03/2009 - 09:52 |

uptown.mc

Please fill out the form below.

Last Name: *

First Name: *

Gender: *

	male	female
Gender

Birthdate: *

Billing Address: *

City: *

State: *

Zip Code: *

Home Phone: *

Emergency Contact: *

	YES	NO
Is the home phone number the emergency contact number?

Cell Phone (Student):

Cell Phone (Parent): *

Emergency Contact: *

	YES	NO
Is the parent’s cell phone number the emergency contact number?

Email 1: *

Email 2:

What school do you attend?: *

Instrument you wish to receive lessons on?: *

Have you played this insturment before?: *

	yes	no
Have you played this insturment before?

Do you currently or have you played any other instruments?: *

	yes	no
Do you currently or have you played any other instruments?

What styles of music do you listen to, or would like to learn? : *

Do you have any special needs or health issues we need to be aware of?: *

Can we use your image in promotional materials?: *

	yes	no
Can we use your image in promotional materials?

Do you have a preferred day and or time frame for lessons?: *

Do you have a preferred teacher for your private lessons?: *

Are you interested in doing classes and workshops along with private lessons?: *

	yes	no
Are you interested in doing classes and workshops along with private lessons?

When would you prefer to meet with our enrollment manager to solidify the rest of the enrollment process?:

Any questions or comments?:

Uptown Music Collective

848 West Fourth St.

Williamsport PA 17701

(570) 329-0888

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