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Keys to

S uccess

Keys to

S uccess

Keys to Success

Student Information
Student Name:________________________ Students Birthday (DD/MM/YY):_____________
Parents Name:_______________________________________________________
Address:____________________________________________________________
Phone Numbers:
Name/Cell_____________/____________
_____________/____________
_____________/____________
_____________/____________
Emails:_____________________________ ______________________________
How often is email checked:______________________________________________
Preferred method of contact:______________________________________________
Emergency Contact Name & Phone Number:___________________________________
Allergy Information:____________________________________________________
Rate the level of students enthusiasm for starting lessons (1 being the least and 10 being the greatest):
1
2
3
4
5
6
7
8
9
10
Students School:_______________________ Favorite Subject:__________________
Hobbies or Interests:___________________________________________________
On a scale of 1 to 5 (1 being the least and 5 being the greatest) how important is your childs
participation in other extra-curricular activities?
Sports
1
2
3
4
5
Times per week:__________________
School clubs
1
2
3
4
5
Times per week:__________________
Church Activities 1
2
3
4
5
Times per week:__________________
Other
1
2
3
4
5
Times per week:__________________
Musical background:___________________________________________________
Does anyone in the family play the piano, or any other musical instruments:
__________________________________________________________________
What goals do you have for your child in the area of music?
__________________________________________________________________
What type of piano do you have or plan to purchase for your home:____________________

Keys to

S uccess

Keys to

S uccess

Please estimate how long the student will be able to practice each day:__________________
Is the parent available to help the student with their practice as needed?________________
What have you decided will be your practice schedule for each day?
__________________________________________________________________
Which payment method would work best for you:
Cash

Check

I agree to provide and buy my

childs piano books. (Please make sure
that you buy/order them well in advance
so you know you have the right book and
have them the lesson theyre needed.)

Mubus an online secure website with

automatic payment options
I would like to be billed the cost of my
childs piano books and shipping (at a teachers
discount) in the next semesters tuition.

Group lessons are mandatory. They will take the place of the individual lesson for that week.
They require a lot of preparation on the teachers part so please be considerate to arrive timely.
Provide a brief description of your child, including temperament, learning style, what motivates
them, and any other information that you feel would enable me to better understand and teach
them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Any concerns, or anything else you would like the teacher to know?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
See the following page for availability

Keys to

S uccess

Keys to

S uccess

Please check availability for Master Classes or lessons during this semester:
Time

9:00

9:30
10:00
10:30
11:00
11:30
12:00
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday