Piano Student Summer Enrollment Form

Ericas Piano Studio, LLC

Name:__________________________________________ Date:_______________________

Fill out the section below if there have been any changes in the following:
Age:______________
Street Address:________________________________________________________________
City:______________________________ State:_______________ Zip:__________________
Home Phone:____________________ Best Time to Call: ____________________________
Fathers Name/Cell:___________________ Mothers Name/Cell:______________________
Email:________________________________________________________________________
Type of Piano/Keyboard: _______________________________________________________

List your first three choices of a lesson time:

1. Day: _______________________ Time: _______________________
2. Day: _______________________ Time: _______________________
3. Day: _______________________ Time: _______________________
List vacation dates: ___________________________________________________________
(I will plan up to 2 makeup lessons due to summer vacations.)
Siblings taking lessons: ________________________________________________________
Special needs: ________________________________________________________________
Other comments: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Policy Agreement: "I have read the 2015-2016 Piano Policy and I agree to abide by the
terms and conditions in the policy."
Signed: _____________________________________________

Date: ________________