PAULETTE ALBERTSON, NCTM
1298 Via Cerro Colorado
Sahuarita AZ 85629
520-398-6758 * 520-237-8030
e-mail: paulette@musical-hands.com
website: http://www.musical-hands.com/

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 _____

8. 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. Other Activities the Student is Currently Involved in: _______________________

___________________________________________________________________________

11. Do you object to the student's picture being on my website? ________________

12.      12. In Order To Avoid Assigning A Piece 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 _____________________

 

CLICK HERE to view this form in .pdf format