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Student Contact information Registration Form
Kubota Music Studio
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* Indicates required question
Email
*
Your email
Student Name (First and Last name)
*
Your answer
Student's Date of Birth (Month/date/year)
*
MM
/
DD
/
YYYY
2nd Student Name (First and Last name)
Your answer
2nd Student's Date of Birth (Month/date/year)
MM
/
DD
/
YYYY
Mother's Full Name
*
Your answer
Father's Full Name
*
Your answer
Guardian’s Full Name
Your answer
Home Address
*
Your answer
Home Phone number
*
Your answer
Mobile Phone number
*
Your answer
Email
*
Your answer
Does the student have experience of piano lessons before?
*
Yes (less than 1 year)
Yes (1~2 years)
Yes (more than 2 years)
No
How did you learn about Kubota Music Studio
*
Facebook
Google Search
Baltimore's Child magazine
Mount Washington Improvement Association Newsletter
RCM
MTA Website
MTAGB Website
Refer from Steinway
Refer from Friend
Sakura Japan News
Baltimore Washington Japanese Mailing List
Other:
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Today's Date
*
MM
/
DD
/
YYYY
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