Registration Form
To enroll, please review Academy Policies carefully, complete and sign this form to submit at your initial interview. This is NOT a contract. The lesson day and time slot will be discussed at your interview and will be secured upon receiving two month of tuitions as non-refundable deposit along with the signed contract.

Sign in to Google to save your progress. Learn more
Email *
Student Information
Student - First & Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Phone Number *
Email *
Parent Information
Parent - First & Last Name *
Address *
Phone Number (Home) *
Phone Number (Cell) *
Phone Number (Office) *
Email *
Spouse/Other Guardian
please fill if neccessary
Spouse/Other Guardian - First & Last Name
Address if different than above
Phone number (Home)
Phone Number(Cell)
Phone Number( Office)
Email
Please list your 3 top choices of your preferred day and time. 
Currently there is no availability on Fridays, Saturdays and Sundays.  If you’d like to have your lessons earlier in the days, please specify. 
 *
Emergency Contact *
Who would you like us to contact first? Add name & member for other option
Required
If you checked “other” above, please fill the contact information below. *
Please note any allergies (including allergies to medicines) that we should be aware of in case of emergency.
Please sign below to indicate that you have read and agree to Academy Policy on our website.
Student Signature and date *
Parent signature and date *
Media Consent

I hereby grant permission for images and/or audio/video of myself and my child(ren) to appear in marketing materials for MDA Piano Academy.
 *
Required
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms