Student Name
*
First Name
Last Name
Student's pronouns
Parent/Guardian Name
*
If applicable
First Name
Last Name
Email Address
*
Cell Phone
*
(###)
###
####
Zip code
*
Student Age
*
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
College student
Adult
Lesson Duration Preference
*
Please select all that apply.
Location Preference
*
You can choose more than one.
Instruments/Topics
*
Please select all that apply.
Teacher Request
*
You can choose more than one.
Please tell us about the student.
How did you hear about Earth Song?
Emergency Contact
*
First Name
Last Name
Emergency Contact's Relationship to the Student
*
Emergency Contact Cell Phone
*
(###)
###
####
Does the student have any allergies we should know about?
I have read the 2023-2024 Studio Policies and agree to all the terms as written.
*
I have read the 2023-2024 Cancellation Policy and agree to all the terms as written.
*
I have read the 2023-2024 Monthly Tuition Policy and agree to all the terms as written.
*
I understand that I must register for an Acuity Scheduling Client Account in order to view/cancel/reschedule my lessons.
Earth Song Creative Arts has my permission to use photos and/or videos of my student(s) on the studio website, social media accounts, or other publications.
*
If you answered "other," please elaborate.
