Registration Form

Register with us to sign up for lessons!

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

Last Name*

First Name*

Address*

Phone Number*

Secondary Phone Number

Email*

Password

How did you hear about us?InternetWalk-inFriend/FamilyOther

Student Info Section

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

InstrumentViolinViolaCelloBassPianoGuitar

LevelBeginnerIntermediateAdvanced

Special Needs/Concerns (please specify)

Scheduling

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 4:30PM-5:30PM

You MUST pick three DIFFERENT blocks of time.

First Time Availability— Please select one —Monday 1-3pmMonday 3-5pmMonday 5-7pmTuesday 1-3pmTuesday 3-5pmTuesday 5-7pmWednesday 1-3pmWednesday 3-5pmWednesday 5-7pmThursday 1-3pmThursday 3-5pmThursday 5-7pmFriday 1-3pmFriday 3-5pmFriday 5-7pmSaturday 9-11amSaturday 11am-1pmSunday 9-11amSunday 11am-1pm

Second Time Availability— Please select one —Monday 1-3pmMonday 3-5pmMonday 5-7pmTuesday 1-3pmTuesday 3-5pmTuesday 5-7pmWednesday 1-3pmWednesday 3-5pmWednesday 5-7pmThursday 1-3pmThursday 3-5pmThursday 5-7pmFriday 1-3pmFriday 3-5pmFriday 5-7pmSaturday 9-11amSaturday 11am-1pmSunday 9-11amSunday 11am-1pm

Third Time Availability— Please select one —Monday 1-3pmMonday 3-5pmMonday 5-7pmTuesday 1-3pmTuesday 3-5pmTuesday 5-7pmWednesday 1-3pmWednesday 3-5pmWednesday 5-7pmThursday 1-3pmThursday 3-5pmThursday 5-7pmFriday 1-3pmFriday 3-5pmFriday 5-7pmSaturday 9-11amSaturday 11am-1pmSunday 9-11amSunday 11am-1pm

Please list any conflicts with the selected times

I agree to all policies, terms and conditions of the Lefferts Gardens Music School

Initial/E-signature