Registration Form

* Indicates required field

Name of Student *

First

Last

Date of Birth (mmddyyyy) *

Age *

School *

Grade *

Name of Student *

First

Last

Date of Birth (mmddyyyy) *

Age *

School *

Grade *

Name of Student *

First

Last

Date of Birth (mmddyyyy) *

Age *

School *

Grade *

Parent / Guardian Name(s) *

Email *

Phone Number *

Select One *

Alternate Email *

Alternate Phone Number *

Select One *

Home Address *

Choose Your Instrument *

Piano Voice Guitar

Preferred Lesson Location *

949 West End Ave In Home

Length of Lesson *

30 min 45 min 60 min

Scheduling - Please check all possible times.

Preference - Please let us know your top three choices for lesson times, and please specify your preferred times if you selected "Other". *

Anything else you'd like us to know about you. *

I give permission for my child's picture or video (such as those taken at a recital or master class) to be posted on the studio's website. *

Yes No

I have read and agree to the studio policy of Broadway Music Studio,
including all information regarding tuition, payments, and cancellations.

Please check the box to provide your signature below. *

By checking here, I certify that I have read and agree to the studio policy.

Submit