REGISTRATION FORM

PRIVATE PIANO INSTRUCTION

After placement has been confirmed, new and returning students must complete and submit the Registration Form, registration fee, first month’s tuition, and the book fee (to be determined by instructor).  The Registration Form and total payment must be received within three (3) calendar days of placement acceptance or the first day of your piano lesson, whichever comes first.  Failure to submit your Registration Form and payment as specified above could result in loss of your placement.

Registration Fee

$25.00 (per family living in the same household)

Monthly Tuition Fees

Length of Lessons	No. of Lessons Per Month	Monthly Tuition Payment
1/2 hour per week	4	$100.00 per month
1 hour per week	4	$200.00 per month

{Student Information}
Firstname:		Lastname:
Address:		City:
State:	Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip:
Home Phone:	- -
{Minor Student}
Date of Birth:	/ YYYY 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 MM 01 02 03 04 05 06 07 08 09 10 11 12 / DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Age:
School:		Grade:
Mother's Name:		Home Phone:	- -
Work Phone:	- - ext:	Cell Phone:	- -
Email - required:
Father's Name:		Home Phone:	- -
Work Phone:	- - ext:	Cell Phone:	- -
Email - required:
{Adult Student}
Work Phone:	- - ext:	Cell Phone:	- -
Email-required:
{Additional Student Information}
Piano at Home:	YES NO
I found out about Bryant's Music by:	NONE FRIEND NEWSPAPER YELLOW PAGES FLYER/BROCHURE BM STUDENT/PARENT OTHER FAMILY MEMBER WEBSITE
Referral Person:
Type of Program:	GOSPEL JAZZ CLASSICAL R&B ALL
Musical Background:
Musical Goals:
{Lesson and Payment Information}
Start Date:	/ YYYY 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 MM 01 02 03 04 05 06 07 08 09 10 11 12 / DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Time Slot:
Instructor	Elaine Bryant Dorothy Critchlow	Length of Lessons 1/2 Hour 1 Hour
Fees	Registration Fee $   Tuition $   Books $   Total Fees $

Upon submission of this Registration Form, I certify and acknowledge that I have read the financial policies, including the Missed Lesson Policy as stated on the Bryant’s Music website (www.bryantsmusic.com) and clearly understand, accept, and agree to abide by the terms herein.