Student's Name *

First Name

Last Name

Student's Phone *

(###)

###

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Parent/Guardian Name

Required for all students under 18.

First Name

Last Name

Parent/Guardian Phone*

*If different from student

(###)

###

####

Preferred Method of Contact *

Phone

Email

What lesson package are you interested in? *

4-week, 30 minutes

4-week, 45 minutes

4-week, 60 minutes

Do you need an instrument rental? *

Instrument rentals are an additional $45 per month charge.

Yes

No

Policies *

I understand and accept the policies of the Berkshire Music School.

Yes

No

Statement of Accuracy *

I certify the above information is accurate.