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Interest Form

New Student Form

Guardian Name

Guardian Email

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Student First Name

Student Last Name

Guardian Phone

Student Birthday

Month

Day

Year

Student School

Student Grade

Student Age

Student Prior Years of Piano

This helps the teachers know what books to give them and where to start!

Emergency Contact Name

Emergency Contact Phone

Authorized Pickup Persons & Contact Info

Please let us know who is allowed to pick up your child outside of the guardian listed on the form.

Preferred Method of Contact

Email

Phone

Other

What kind of piano do you have at home?

This allows the teacher to appropriately suggest different way to practice.

Do you own an iPad?

Yes

No

This allows teachers to assess if any online learning tools could be successful

Student Hobbies & Interests

Does the student play any other instruments?

Has the student looked forward to lessons?

Yes

No

In Between

Motivation can play a big part in how lessons are structured!

Please describe how your child exhibited an interest in music, if applicable.

Do any family members play piano or any other musical instruments?

Does the student have any long-term goals or expectations from taking piano?

Do the guardians have any long-term goals or expectations from piano lessons?

My child will set aside regular time to practice piano and the guardian will help oversee this.

Yes, I'm ready to do so!

I have questions about this

If you believe it would benefit the learning experience, please feel free to discuss below if the student has a handicap, disability, or health concern.

Where did you hear about Samantha Simpson Piano Studio?

If someone referred you, please list their name.

I am aware of the quarterly/semesterly pay schedule.

I have, to the best of my knowledge, filled out this form correctly and will notify the company if any information should change.

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