Please complete the information requtested below and return this page to me.  Your date of birth and grade are
required for participation in several music events.   

Student’s Name: ______________________________________

Parent’s Name’s: ______________________(mom)  ______________________(dad)

Date of Birth: ___________________     Years of Lessons:________________

Prior Teacher(s) ____________________________________________________

Grade:  ____________        School _____________________________________

Street: ____________________________________________________________

City, State, Zip ____________________________  _______________  ________

Mom's or Dad's Email: __________________________________________________

Student E-Mail: ____________________________ Student Cell:________________________

Phone: (home)  ________________________  (work)_______________________

(cell)  __________________________ (fax) ________________________      

Start Date at
Barbara Taylor Music Studio: ___________________________

TO BE SIGNED BY STUDENT or PARENT as applicable:   

I have read and understand the Barbara Taylor Music Studio Letter on the prior page and will ensure that they
are followed.  I further understand that Barbara Taylor has the right to terminate lessons should any of the
policies be broken and discussions do not lead to the desired and on-going agreed to action(s) or behaviors.

Signature:    _________________________________________

Date: ______________________________

I give permission to post student's pictures on web site and facebook ___Yes___No

Briefly state your musical goals (Use reverse side of paper, if necessary):