EmailMe Form - SGM Lessons Student Registration

Are you a Groupon Customer? *

Yes

No

Enter Groupon Voucher

Student Name

First Last

Student Age

Date of Birth

MM/DD/YYYY

Student Sex (Female students under 18 require a parent present during lessons)

Student Phone

### - ### - ####

Student Email

Student Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Parent Name

First Last

Required if student is under the age of 18

Parent Phone

### - ### - ####

Required is student is under the age of 18

Parent Email

Required if student is under the age of 18

Parents Address

Street Address City State / Province / Region Postal / Zip Code Country / Region

Requied if student and parent do not reside in the same household

Lesson Information

Please indicate your preferences

Instrument

Lesson Day
First Choice

Time Availabilty (Lessons run from 2pm-7pm Mon-Thur)

Lesson Day
Second Choice

Time Availabilty(Lessons run from 2pm-7pm Mon-Thur)

Lesson Length

30 minute (Groupon)

45 minute

60 minute

Frequency

Twice a Week

Weekly

Bi-Weekly

Do you wish to study more than one instrument?

Yes

No

If so, please indicate which 2 instruments you wish to study.

Guitar

Bass

Check all that apply

Lesson Information

We look forward to working with you!