Student's Name *

First Name

Last Name

Student's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Date of Birth *

MM

DD

YYYY

Student's Phone *

(###)

###

####

Parent/Guardian Name

Required for all students under 18.

First Name

Last Name

Parent/Guardian Address*

*If different from student

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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 $50 per month charge.

Yes

No

Preferred Location *

Pittsfield

Adams

Virtual

Photo and Media Release *

I allow the Berkshire Music School the use of any photographs, video, art work, and recordings made at the school or school functions.

Yes

No

Policies *

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

Yes

No