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Registration Form OLD

Register with us to sign up for lessons!

Top part – to be filled out by adult, parent, or guardian.

Last Name*
First Name*
Phone Number*
Secondary Phone Number
How did you hear about us?
If you are the student, put your information again below.
If your child is the student, put the child’s information below.
Is the student an adult? Check this box if yes.
Student Last Name
Student First Name
Student Address
Student Birthdate (MM/DD/YYYY)
Student Phone Number
Student Email
Special Needs/Concerns (please specify)
In order to provide all of our students with lesson times that will work with their schedule, we are asking parents to select their first, second, and third choice block of time. The blocks are 2-hours long, and if you are not available during the full 2-hour block, you can leave a note in the comment box.
Example: Susie is only available on tuesday from 430PM-530PM
You MUST pick three DIFFERENT blocks of time.
First Time Availability
Second Time Availability
Third Time Availability
Please list any conflicts with the selected times
I agree to all policies, terms and conditions of the Clinton Hill Music School