Student name _________________________________Nickname____________________
Birthdate ___________ Age ____ Name of School ______________________________Grade____
Number of years you have studied piano ___What other instrument do you play? ___________
Do you participate in a middle or high school band? ____ If "yes," name of band director
___________________________________(This information is needed if FBA participation is desired.)
Any known allergies? ____________________________________________________________
Parents’ Names __________________________________________________________
Address (if different form previous contract) ______________________________________ zip _________
Phone #’s: Please indicate whose number belongs to whom: home ____________work#1 ___________
work #2 _____________ cell #s ______________ _______________ _________________
Parents e-mail ___________________________________________________________
Student’s e-mail: ________________________________________________________
Course/ Study option (check one): traditional ___ collaborative ___ competitive ____
Preferred method of Payment (check one):
____ one-time payment ($1700.00) (students on probation not eligible for this option)
____ quarterly ($450.00/4 quarters) ____ monthly ($185.00/ten months; August –May)
¯ Note: This is not a bill; adjustments for scholarships and 2nd 3rd child tuition reductions will be calculated on forthcoming bills ¯
I have read and agree to bide by all the terms and conditions specified in the Syllabus.
_________________________________ ______________________________________
(Name of Parent: print/sign)
Please sign and return to me by 30 July 2011