Student  Name(s):_______________________________________________________          Age:__________              Grade:________  

Parent(s)  Names:_____________________________________________________________________________________________  
Address:_______________________________________________________________________________________________________  
_________________________________________________________________________________________________________________  
 
Home  Phone:____________________________  Parent  Cell  Phone(s):____________________________________________  
 

 

 

 

 

 

 

 

             ____________________________________________  

 
Student  E-­‐mail  Address:_______________________________________________________    Checked  regularly?_______  
Parent  E-­‐mail  Address:________________________________________________________    Checked  regularly?_______  
 
Do  you  own  a  piano  or  keyboard?______________________  
Please  describe  the  type  of  piano/keyboard  (brand,  model)_____________________________________________  
 
Other  hobbies,  interests  or  activities:______________________________________________________________________  
_________________________________________________________________________________________________________________  
 
***Parents  or  Guardians:  
Please  list  any  additional  information  you  deem  necessary  for  your  student’s  success  or  any  
additional  contact  information  you  wish  to  be  known.  ___________________________________________________  
_________________________________________________________________________________________________________________  
_________________________________________________________________________________________________________________  
 
Occasionally,  I  might  like  to  send  various  piano  or  music-­‐related  links  and  articles  to  certain  
students  who  may  be  interested  in  certain  topics  or  simply  for  inspiration.    I  will  copy  you  on  each  
e-­‐mail  I  may  send  to  your  student.    Do  I  have  your  permission  to  do  so?  _______________________________  
 
Parent/Guardian  Signature:  ________________________________________________________________________________