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Email: Enter Email

Student Gender:

Male

Female

School Name (if minor):

Grade:

Ethnicity:

African American/Black

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Hispanic/Latino

Native American

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Other

Father's Name (if minor):

Mother's Name (if minor):

Home Address: Enter Address

City: Enter City

State: Enter State

Zip code: Enter Zip

Country: Enter Country

Home Phone: Enter Phone Number

Work Phone: Enter Phone Number

Cell Phone: Enter Phone Number

Student's Date of Birth: MM/DD/YYYY

Preferred Method of Contact:

Father's Employer:

Mother's Employer:

Preferred Area of Instruction:

Piano

Drums

Guitar

Bass

Voice

Brass/Woodwind

Other

Length of Lesson:

30 minute weekly lesson

1 hour weekly lesson

Media Waiver:

I DO give CSMA permission to use photos of me and/or my child in printed materials or on the company website.

I DO NOT give CSMA permission to use photos of me and/or my child in printed materials or on the company website.

Student Name: Enter Name

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