Piano Student Enrollment Form

Ericas Piano Studio, LLC

Name:__________________________________________ Date:_______________________
Birthday:______________________ Age:______________ Grade:_____________________
Street Address:________________________________________________________________
City:______________________________ State:_______________ Zip:__________________
Home Phone:____________________ Best Time to Call: ____________________________
Fathers Name/Cell:___________________ Mothers Name/Cell:______________________
Email:________________________________________________________________________
Type of Piano/Keyboard: _______________________________________________________
Previous Musical Experience: (Please indicate former teachers, instruments studied, and
years studied) _________________________________________________________________
______________________________________________________________________________
Why do you want to take piano lessons? Do you have any goals that you wish to
achieve in music?______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
List your first three choices of a lesson time:
1. Day: _______________________ Time: _______________________
2. Day: _______________________ Time: _______________________
3. Day: _______________________ Time: _______________________
Siblings taking lessons: ________________________________________________________
Special needs: ________________________________________________________________
Parents Musical Experience: ____________________________________________________

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: ________________