Parent Name *

First Name

Last Name

Student Name *

First Name

Last Name

Phone *

(###)

###

####

Area of Study *

Check all that apply

School Audition Prep for Percussion: e.g. BAK Middle School for the Arts

Snare Drum

Xylophone/Bells

Drum Set

Beginner Guitar

Music Theory

Does the student have the instrument for weekly practice? *

Yes

No

Length of Lesson *

30 min

60 min

Is the student enrolled in public school or being homeschooled? *

Homeschooled

Homeschooler with FES-UA or PEP Scholarship

Public School Student

Location for lesson *

Getz Arts Studio in WPB

In-Home

Address - required for In-Home

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

For In-Home only: Is the distance further than 15 min from WPB?

Anything further than 15 min for In-Home are subject to additional fees and/or minimum of 60 min

Yes

No