Enrollment Form

Student Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Address (for in-home lessons only)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Instruments *

Piano

Guitar

Drums

Violin

Voice

Bass

Ukulele

Technology for Music

Has the student had any previous music instruction? *

Yes

No

Please check to AGREE with the following policy *

I agree that if the student is under 18 years old, there must be an adult other than the instructor on the premises at all times during the lessons. At the El Segundo Arts Academy location, parents and guardians have full access to the lesson rooms and may enter or sit in at any time during lessons. The rooms also have large windows, allowing them to observe from outside.

Date *

MM

DD

YYYY