Session Registration Form

I am registering for: *

Fees are NOT adjusted for missed individual or group lessons. Your monthly fees reflect a payment towards your complete season fee. Your selections below are for the full season of Sept-May.

(10) 45 minute ADULT piano lessons: $480

(6) Trial Lessons: $180

I would prefer to pay my tuition:

2-Monthly Payments

One-time Full payment

I am aware there is a materials fee of $50 for Adult lessons and/or $35 for the trial session *

Yes

Please check: *

New Student

Returning Student

Student Name *

First Name

Last Name

Birthday

MM

DD

YYYY

Current Address

If this is your first registration form, please provide your current contact information (even if it has not changed from last season). If you are registering multiple students, you may skip this info for subsequent registrations.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

(###)

###

####

Secondary Phone Number

(###)

###

####

Health Concerns related to Music Education *

None

Hearing challenges

Wears corrective eyewear/Vision impaired

Diet restrictions

ADD/ADHD

Where are we right now? *

Please check all that apply to your current level of music education

Reads basic music

Plays the piano

Plays another instrument

Is an active musician

Has formal music education

No music experience.

PHOTO PERMISSION

Please check all that apply. Note that any public postings will NOT include biographical or performance information.

MY PICTURE MAY NOT BE INCLUDED in any posted photographs of Little Ears Studio.

*

OPTED OUT ABOVE.

MY PICTURE MAY BE INCLUDED in photographs for the following reasons:

----- On the PRIVATE website

----- In PUBLIC promotions or portions of the website

----- As part of photo displays at performance events such as recital or Christmas party

---- In Mrs. Tallamy's personal social media accounts (all marked as private). This note is included as family pictures are shared on Facebook. Due to the nature of our school, piano students often become part of these pictures.

I am interested in performing:

in church

at the Christmas Party

at the Spring Recital

at family holiday gatherings