Harmanny Music Education Spring Sign Up Form
Please fill in the answers below
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Email *
Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Grade (if adult or preschooler, leave blank)
School (If adult or preschooler, leave blank)
Mother's Name (if adult student, leave blank)
Father's Name (if adult student, leave blank)
Phone *
(Parent) Email address *
Mailing address *
Preferred method of contact (in case of cancellation) *
Emergency Contact (If parent cannot be reached) *
What instrument(s) is the student interested in learning? *
What is your preference for day of the week for your lesson? Please check the available times at harmannymusiceducation.com/lesson-schedule *
What is your time preference for individual lessons (available Sunday-Friday)? *
3:00-3:30
3:30-4:00
4:00-4:30
4:30-5:00
5:00-5:30
5:30-6:00
6:00-6:30 (Sunday and Monday only)
I am an adult, preschool or homeschool student and would like a time during the day before 3:00
I would like the self-paced, online option (don't need a time!)
1st choice
2nd choice
3rd choice
I am not interested in in-person lessons, but only the online, independent study option. 
Other Extracurricular Activities *
Does either parent (or students) have musical training? If so, what instrument and how many years? *
Other children? (Names and ages) *
What are the goals for music education? *
Does student have access to instrument for practice at home? *
Does the student have any unique attributes, physical or learning challenges that may affect their ability to learn music? If so, what are they? *
If you were referred by a current student, who referred you?
I have read and agree to follow the policies for the  music lessons found here: https://drive.google.com/file/d/1J5Tq7wgT1wjIcpOVXOCDEsM6B_IEvkLF/view?usp=sharing *
Harmanny Music Education has permission to use my child’s (under 18) likeness on social media (Harmanny Music Education website, Facebook/Instagram/Twitter) *
Student's Favorite Candy *
Student's Favorite Song/Musical Style *
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