BROADWAY MUSIC STUDIO
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Keiji Ishiguri
Jonathan Drucker
Helen Kashap
Danny Parente
Cindy Snell
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Broadway Music Studio
2017-2018 Registration Form
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Indicates required field
Name of Student
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First
Last
Date of Birth (mmddyyyy)
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Age
*
School
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Grade
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Name of Student
*
First
Last
Date of Birth (mmddyyyy)
*
Age
*
School
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Grade
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Name of Student
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First
Last
Date of Birth (mmddyyyy)
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Age
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School
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Grade
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Parent / Guardian Name(s)
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Email
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Phone Number
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Select One
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Cell Phone
Home Phone
Work Phone
Alternate Email
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Alternate Phone Number
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Select One
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Cell Phone
Home Phone
Work Phone
Home Address
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Choose Your Instrument
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Piano
Voice
Guitar
Preferred Lesson Location
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W 102nd St
In Home
Boston Area
Length of Lesson
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30 min
45 min
60 min
Scheduling - Please check all possible times.
Monday
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3pm - 5pm
5pm - 7pm
7pm - 9pm
Other
None
Tuesday
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3pm - 5pm
5pm - 7pm
7pm - 9pm
Other
None
Wednesday
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3pm - 5pm
5pm - 7pm
7pm - 9pm
Other
None
Thursday
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3pm - 5pm
5pm - 7pm
7pm - 9pm
Other
None
Friday
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3pm - 5pm
5pm - 7pm
7pm - 9pm
Other
None
Saturday
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9am - 11am
11am - 1pm
1pm - 3pm
3pm - 5pm
Other
None
Sunday
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9am - 11am
11am - 1pm
1pm - 3pm
3pm - 5pm
5pm - 7pm
Other
None
Preference - Please let us know your top three choices for lesson times, and please specify your preferred times if you selected "Other".
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Anything else you'd like us to know about you.
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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.
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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