Student Registration Form

Student name: ___________________________________ Date of birth: _____________

Address: ________________________________________________________________

City: ______________________________ State: ___________ ZIP:________________

Primary Phone: __________________ Additional Phone: _________________ H W M (circle)

E-mail: ______________________________________________________

Parent(s)/Guardian(s) Name(s):

_____________________________________________________________

Date of first lesson: _______________

Instrument (please circle): Violin/Fiddle Viola Cello Piano

Notes/Comments:

I have read the policy of the Sexton Music Studio and agree to its terms.

__________________________________ _________________

Signature of Student (if over 18) Date

Or Parent/Guardian