Contact

student registration form

* Indicates required field

Name (please register each student separately) *

First

Last

Registration is for: *

Summer, 2019 Fall, 2019

Choose One *

Continuing student Transfer Student New Student

Best Phone Number (leave blank if continuing student) *

What type of phone line is it? *

Alternate Phone Number *

What type of phone line is it? *

Email address *

Parent name(s) if applicable *

Address (leave blank if continuing student) *

Line 1

Line 2

City

State

Zip Code

Country

Choose one *

Please list all times you are available for piano lessons Mondays through Fridays *

Please list all dates you won't be able to attend for the term (summer term is prorated). *

How did you hear about Adam Revell? *

Comments or questions *

By registering for piano lessons on a weekly basis, I am paying for a weekly scheduled time, and am committing to being present and on time to scheduled lessons. I have read the piano lesson policies and understand them.

Please select one *

I agree, and wish to register I am contacting you about something else (please indicate in the "comments or questions'" field)