Arbutus Music Academy, Vancouver- New Student Registration.

Private Lessons Registration Form

Your Name(Required)

First Last

Student's First and Last Name (if different from you):

First Last

Lesson Type:(Required)

Student's Date of Birth ( month and year for a child, or type Adult)(Required)

Email(Required)

Mobile Phone(Required)

Alternative Phone

Address(Required)

Street Address Address Line 2 City Province

Day School and Grade (if the student is a child):

Desired Lesson Duration

Student's Level:

Your Instructor:(Required)

Scheduled Lesson Day and Time:(Required)

ex. Monday at 3:30pm

Special circumstances, allergies, or medical conditions we should know about:

How did you hear about us?(Required)

Photo Consent

By checking this box, I give my consent to AMA to use photos/videos taken during lessons for promotional purposes only, with no names attached.

Name

This field is for validation purposes and should be left unchanged.