Quentin Road Music Lab                                                                                 Click here to downoad the form

          Quentin Road School of Music

(please print and complete and bring to your first lesson)

First Name: ____________________ Last Name: _____________________

Date of Birth: ______/______/______   Today’s Date: _____/______/______

Father’s First Name: ____________  Father’s Last Name: ________________

Mother’s First Name: ____________ Mother’s Last Name: ________________

Siblings First Names: ____________________________________________

Address: ______________________________ City: ___________________

State: ____________________________ Zip: _______________________

Home Phone: __________________ Cell Phone: _______________________

Email: ____________________________@ ________________. ________

Instrument you would like to learn ___________________________________

Have you played before? _________________ If so, how many years?________

Who was your teacher? ___________________________________________

How will you be paying for your lessons? Cash _____ Check____ 

Office Use:

Teacher: _____________________________________________________

Date Started: __________________________________________________