www.KwanMusic.com

All fields marked by asterisk ( * ) are required.

Instrument*	Lesson Type*































FAMILY INFORMATION

Mother's First Name* Last Name*

Email address* Work #	Cell # *

Father's First Name* Last Name*

Email address* Work #	Cell # *

Home Address Line 1*

City* State*	Zip*

Home #

STUDENT INFORMATION

Choose one of the following*:
New Student Returning Private Student	Returning Group Class Student

Student's First Name* Last Name *	Birthday*

Gender*:
Male Female

School attending*





ADDITIONAL INFORMATION ABOUT STUDENT

Previous Music Experience (Please describe previous music experience; place NA if none)

QUESTIONS OR CONCERNS



PAYMENT INFORMATION:

ECHECK/BANK DRAFT We do collection via ACH-autopay. Please fill out the following Payment Method:

Routing Number* Account Number * Name on Bank Account *

Bank Name* Account Holder Phone *