Changing Lives through Music Education Start Your Journey Student First Name* Student Last Name* Student Birthdate* --None-- January February March April May June July August September October November December --None-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Student Preferred Pronouns --None-- She/her He/Him They/them Prefer not to say Other Desired Instrument of Study* Harp Piano Violin Viola Cello Desired Lesson Type* 30-minute lessons with faculty teacher 45-minute lessons with faculty teacher 60-minute lessons with faculty teacher Adults-only: One 60 minute lesson per month Adults-only: Two 60 minute lessons per month Suzuki violin group class ages 3-5 Demographic Identification Φ American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White Bi-racial I prefer not to say Other Student's Previous Musical Experience If student has any learning differences, please describe: If you are completing this form for a student under 18, please provide your own name and contact information below. If you are an adult student, please provide your own name and contact information. Primary Contact: Relationship to Student* --None-- Self Mother Father Sibling Grandmother Grandfather Aunt Uncle Cousin Friend Legal Guardian Other First Name* Last Name* Email* Phone* Street* City* State* Zip* Use the space below to provide information for additional adults who would like to be contacted by the school (ex. parents). Adult Contact (1): First Name Last Name Relationship --None-- Mother Father Sibling Grandmother Grandfather Aunt Uncle Cousin Friend Legal Guardian Other Phone Email Adult Contact (2): First Name Last Name Relationship --None-- Mother Father Sibling Grandmother Grandfather Aunt Uncle Cousin Friend Legal Guardian Other Phone Email Comments
