STUDENT QUESTIONNAIRE
1. Name of Student_________________________________________________________________________________________
2. Names of Parents/Guardians_____________________________________________________________________________
3. Address of Student______________________________________________________________________________________
4. Parents'/Guardians' Address (if different)______________________________________________________________
5. Phone Numbers (Home and Work)______________________________________________________________________
__________________________________________________________________________________________________________
6. E-Mail Address___________________________________________________________________________________________
7. Student's Birthdate______________________________________________________________________________________
8. A. Homeschooled _____, Grade Level _____
B. Public or Charter School _____, Grade Level _____
9. If Student has studied piano before I need to know his/her total years of study __________________________
10. Will the student be practicing on a piano _____ or an electronic keyboard _____? If keyboard, how many
keys does the keyboard have? ______
11. Other activities the student is currently involved in:
__________________________________________________________________________________________________________
12. Does this student have any disabilities that I will need to work with as we
explore music? __________________________________________________________________________________________
13. Do you object to the student's picture being placed on my website _______
14. In order to avoid assigning music that might be considered by you to be politically incorrect to your
child’s nationality or religious affiliation, it would be helpful if you would supply the following
information. If you choose not to answer I will understand.
Nationality _________________ Religious Affiliation _____________________