Name of the Student Mr./Mrs./Ms.__________________________________________________________________
Address ______________________________________________________________________
_____________________________________________________________________________
Category (Check one): Adult _____________________ Child_____________________
Phone (Day) _______________________________ (Eve.) ______________________________
Phone (Cell 1) ______________________________ (Cell 2) _____________________________
Fax____________________________ Email _________________________________________
Emergency Contact: Mr./Mrs./Ms._________________________ Phone___________________
name: ____________________________________________________________________
Previous Lessons (please describe if any) _____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Signature of Student/Parent/Guardian__________________________ Date _________________
For office use only:
Level: Beginner __________ Intermediate __________ Advance __________ |