Your Name (required):

Date:

Date of Birth:

Current Grade:

Gender:

Address:

Parents/Guardians names:

Home Phone:

Cell Phone:

Email Address:

Previous music experience:

Instrument or class:

Lesson length:

Lesson day and time:

Teacher:

Pediatrician:

Pediatrician phone:

Allergies or medical conditions we should be aware of:

Notes:

Student registration – $25.00- must accompany this form before starting lessons.

 Please make this payable to “I AM Music Academy.”