Fall Class Registration
Personal Info
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Student Name:
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Birth Date:
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Parents' Names:
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Address:
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Email:
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Phone:
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Cell phone:
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Current student?
Yes
No
If no, are you interested in signing up for private lessons?
Yes
No
I'd like more information
Class Info
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Which class[es] would you like to sign up for?
Music Theory 1
General Music 1 (autism)
Mommy and Me Music
General Music 2, Auditory Sense (autism)
Violin Performance Class
Clarinet Performance Class
General Performance Class
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Does your child have a disability that may interfere with his/her participation in the class?
Yes
No
Unsure
If your child has autism and is NOT a current student, please list any needs your child has (i.e. an individual therapist during class, behavioral issues, sensory issues, etc.)
Do you have any other questions or concerns?
Would you like a staff member to contact you regarding this class, private lessons, or anything else? If so, when is the best time?
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I have filled out this form correctly and agree to the studio policies.
Yes
No
Please contact me
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Indicates Response Required
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