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2025 Piano Lesson Enrolment Form
Kimberly's Piano Room
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* Indicates required question
Email
*
Your email
Do you agree to our Studio Policies?
*
Yes, I agree
No, I do not agree
Student's Full Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Parents'/Caregivers' Names
*
Your answer
Phone Numbers
*
Please specify who the numbers belong to
Your answer
Home Address
*
Your answer
Any medical conditions or learning difficulties for the teacher to be aware of:
Your answer
Student's previous/current musical education
*
Your answer
Parents'/Caregivers' musical background
*
Your answer
Why are you enrolling your child in piano lessons?
*
Your answer
What would you like your child to achieve through piano lessons this year?
*
Your answer
How much practice do you expect your child to be able to do during the week?
*
Your answer
What kind of piano/keyboard do you have in your home?
*
Your answer
What kind of lessons would you prefer your child to have?
(please note: $5/month discount with auto payment set up for the 1st of each month)
30-minute solo lessons - $140/month
45-minute buddy lessons - $165/month
45-minute solo lessons - $190/month
Other:
Clear selection
Please tick any times you would NOT be available for piano lessons
Please ONLY tick the times your child would definitely NOT be able to make it to a lesson. Specific preferences will be covered in a later question
2:30
2:45
3:00
3:15
3:30
4:00
4:30
5:00
5:30
6:00
6:30
Mon
Tue
Wed
Thu
Fri
2:30
2:45
3:00
3:15
3:30
4:00
4:30
5:00
5:30
6:00
6:30
Mon
Tue
Wed
Thu
Fri
What school does your child attend?
Your answer
What is the earliest time you could be at a lesson after school?
*
Your answer
What is the latest time your child could finish their lesson?
*
Your answer
What are your ideal lesson times/days?
*
We cannot guarantee anything, but will do our best to accommodate as many preferences as possible
Your answer
Any further comments about lesson availability:
Your answer
Is there any other info that would be useful for us to know so that we can provide the best lessons possible for your child?
Your answer
Do you give permission for photos/videos taken in lessons to be shared for advertising purposes?
*
Yes
No
Other:
There is a $50 registration fee due along with the form
*
This is to hold your place in the schedule and cover some initial music and materials. The bank account number is as follows (it is also on the studio policies document): 12-3167-0138451-00
I have already paid this
I will pay this now
I will pay this within the next 14 days
Other:
Required
A copy of your responses will be emailed to the address you provided.
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