| Last Name* |
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| First Name* |
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| Address* |
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| Phone Number* |
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| Secondary Phone Number |
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| Email* |
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| Username* |
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| Password |
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| How did you hear about us? |
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If you are the student, put your information again below.
If your child is the student, put the child’s information below.
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| Is the student an adult? Check this box if yes. |
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| Student Last Name |
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| Student First Name |
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| Student Address |
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| Student Birthdate (MM/DD/YYYY) |
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| Student Phone Number |
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| Student Email |
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| Instrument |
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| Level |
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| Special Needs/Concerns (please specify) |
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| 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 430PM-530PM
You MUST pick three DIFFERENT blocks of time.
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| First Time Availability |
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| Second Time Availability |
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| Third Time Availability |
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| Please list any conflicts with the selected times |
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| I agree to all policies, terms and conditions of the Clinton Hill Music School |
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| Initial/E-signature |
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