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 Student Information Form
 
Referral Source:
Yellow Pages
Word of Mouth
Internet/Website
Newspaper
Other        
Student Information:
Student Name            Adult        Child        
Date of Birth (required for ECE)          Age        Grade  
Address  
City          NC     VA     Other          Zip Code  
Home Phone          Work Phone  
Cell Phone              Email Address  
Mother            Home Phone            Work Phone    
                                                           Cell Phone                Email Address  
  Father             Home Phone            Work Phone    
                                                           Cell Phone                Email Address  
Interested in (be specific):
Keyboard                Early Childhood  
Vocal                      Camp               
Instrumental            Birthday Party    
Ensembles               Partnership with a school  
Musical Background:
[indicate institution(s) and year(s) of study]		Available for Lessons
Never studied music          Most recent literature completed  8am - 12n    12n - 6pm    6pm - 9pm
Keyboard                Reason/need for lessons    Monday                                 
Vocal                                     Ultimate goal  
  Tuesday                                 
Instrument(s)                 Teacher requested    Wednesday                                 
Ensemble(s)            Thursday                                 
Early Childhood Education               Friday                                 
School Programs(s) [be specific]    
  Saturday                                 
Most recent private teacher                 Sunday                                 
Type of teacher requested; needs and/or personality of students  
Additional Information  

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