Registration For Adult Students Your name Referred by Your level —Please choose an option—BeginnerIntermediateAdvanced Instrument / Class DOB (optional) Occupation Home phone Mobile phone Work phone Your email Street, city & zip Any previous musical experience? NoYes Dates/How long? What instrument or artistic endeavor? MEDICAL INFORMATION & RELEASE (PLEASE LIST ITEMS BELOW) Any Food Allergies? (e.g. Peanut Butter) Any Allergies? (e.g. Dogs, Cats) Any Adverse Reactions to Over-the-Counter-Drugs? (e.g. Tylenol, Advil) Any Other Pertinent Information We Should Know? Emergency Name: Telephone; & Relationship to Student: Doctor’s Name & Telephone: I give permission to administer simple first aid (e.g. Tylenol, Benadryl, antibiotic ointment, etc.) if the need arises. If further medical attention is needed; the emergency contact, doctor, or 911 will be called. I further release the Leslie Kennedy Piano Studio, LLC from any liability for injuries occurring on the premises. PHOTO/VIDEO RELEASE I hereby give permission for images of myself, captured, through photo, video and digital camera, to be used in brochures, websites, posters, advertisements, or other promotional material for Dynamic Music! / Kennedy Piano Studio, LLC. I further waive any rights of compensation or ownership thereto. ADULT STUDENT INFORMATION Any instruments previously studied? NoYes How long? What instrument(s)? What interests you about learning to play a musical instrument? What level of proficiency would you like to accomplish playing a musical instrument? What types of music do you like to listen to? Or, name some of your favorite songs: Any other activities you participate in? (e.g. Play other instruments, Dance; Sports; Hobbies, etc.): Other information that might be useful to know:
