date _____________

Student Information

Student Name ________________________________ Age _____ DOB ________

School ________________________________________ Grade _____

Parent(s) Name(s) _____________________________

Address ____________________________________________________________
Phone Numbers ______________________________________________________

Emails _____________________________________________________________
How often is email checked? ______________________
Preferred method of contact: Home / Cell / Email / Other: _________________
Emergency Contact Name/Phone Number (if other than parent) ______________________
__________________________________________________________________
Allergy Information ____________________________________________________
Is the student looking forward to taking piano lessons? ____________________________
Does the student like school? __________ Favorite subject(s) _____________________
Hobbies or interests ____________________________________________________

Extra-curricular activities ________________________________________________

Musical background ____________________________________________________

Does anyone in the family play the piano, or any other musical instruments? ______________

__________________________________________________________________
*Describe how your student has exhibited an interest in music and the piano. _____________
__________________________________________________________________
Please estimate how long the student will be able to practice each day. __________________

*Is the parent available to help the student with their practice as needed? ________________
Any concerns, or anything else you would like the teacher to know? ____________________
__________________________________________________________________

__________________________________________________________________
*Not applicable to high school or adult students.

For Teacher Only:

Level _______________ Current Repertoire/Materials _______________________________

Notes _____________________________________________________________________

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