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Student's Name *

Birthdate *

School *

Grade *

Parent's Name *

Address

City

State/Province

Zip/Postal

Home Phone *

Cell Phone *

Work Phone

Email Address *

When do you wish to begin lessons? *

Please choose the appropriate program: *

Preferred lesson day (1st Choice): *

Preferred lesson time (1st Choice): *

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Preferred lesson day (2nd Choice):

Preferred lesson time (2nd Choice):

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Do you have siblings that need to be scheduled together?

Yes

No

Would you like to receive statements via email? *

Yes

No

Would you like to sign up for our e-mail newsletter? *

Yes

No

Referred by:

Photo Consent *

Yes, I agree to allow Zhen Music and Arts Institute to use images and likenesses of my child in the promotional materials, website, and social media of the school.

No, I do not agree to allow Zhen Music and Arts Institute to use images and likenesses of my child in the promotional materials, website, and social media of the school.

Release *

I hereby release Zhen Music and Arts Institute Instructors from any and all liability and responsibility in connection with such activities and hereby release all parties from liability by reason of any accident or of injury suffered by said child while engaged in such activities.

Parent's Signature *

Date *

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