Student Name* First Last Student GradePlease choose:Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeFreshmanSophmoreJuniorSeniorCollegeN/AStudent School Student Phone Number (if applicable)Student Email (if over 18) Instrument Lessons Requested: Violin Viola Cello Piano What instruments has he/she played? How long have they played the instrument? Have they had private lessons on this instrument before? Yes No If yes, how long: Parent/Guardian Names* First Last Relationship to student: Parent Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Phone Number*Preferred Phone Type* Mobile Home Work Other Phone NumberOther Phone Type Mobile Home Work Please provide any other information we should know (student health concerns, allergies, etc.)Policies & Procedures*By checking this box, e-signing below, and submitting this form, you state that you have read and agree to follow the Gain Music Academy Studio Policies & Procedures. Yes, I agree Please type your name to e-sign*
