Registration form How did you hear about us? Student Information * required fields Student Name * First Name Last Name Birth date * MM DD YYYY Grade level Gender Female Male Non-binary Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Type of lesson * Voice Piano Voice & Piano Previous experience? Yes No Parent Information Parent Name * First Name Last Name Phone * (###) ### #### Additional Parent Name (optional) First Name Last Name Phone (###) ### #### Emergency Contact Name of contact 1 * First Name Last Name Phone * (###) ### #### Relationship to Student Name of contact 2 First Name Last Name Phone (###) ### #### Relationship to Student Media Release Photos * I hereby grant Alina’s Music Studio (AMS) the right to photograph me (student)/my child to be used in digital media (Facebook/website/etc) and in any other form of electronic or print medium (business cards/brochures/poster/etc) for the sole purpose of business advertisement and promotion. Yes No Video * I hereby grant Alina’s Music Studio (AMS) the right to record a video/audio of me (student)/my child to be used in digital media (Facebook/website/etc) and in any other form of electronic media for the sole purpose of business advertisement and promotion. Yes No Privacy * I understand that my child’s full name, address and biographical information will not be made public. Yes Signature * Date * MM DD YYYY Thank you for registering with Alina’s Music Studio!