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    Last Name*

    First Name*

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    Secondary Phone Number

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    How did you hear about us?

    Student Info Section

    If you are the student, put your information again below. If your child is the student, put the child's information below.

    Is the student an adult?*

    Student Last Name

    Student First Name

    Student Address

    Student Birthdate (MM/DD/YYYY)

    Student Phone Number

    Student Email

    Instrument

    Level

    Special Needs/Concerns (please specify)

    Scheduling

    In order to provide all of our students with lesson times that will work with their schedule, we are asking parents to select their first, second, and third choice block of time. The blocks are 2-hours long, and if you are not available during the full 2-hour block, you can leave a note in the comment box.

    Example: Susie is only available on tuesday from 4:30PM-5:30PM

    You MUST pick three DIFFERENT blocks of time.

    First Time Availability*

    Second Time Availability*

    Third Time Availability*

    Please list any conflicts with the selected times

    I agree to all policies, terms and conditions of the Clinton Hill Music School*I agree

    Initial/E-signature*