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Student Profile

STUDENT 1 (required)

*Student Name:

*Instrument:

*Age: *Date of Birth:

*Gender:

Male

Female

Lesson information (enter if known)

Instructor Name Start Date (within 2 weeks)

Lesson Day Lesson Time Lesson Length

STUDENT 2 (if applicable)

Student Name:

Instrument:

Age: Date of Birth:

Gender:

Male

Female

Lesson information (enter if known)

Instructor Name Start Date (within 2 weeks)

Lesson Day Lesson Time Lesson Length

STUDENT 3 (if applicable)

Student Name:

Instrument:

Age: Date of Birth:

Gender:

Male

Female

Lesson information (enter if known)

Instructor Name Start Date (within 2 weeks)

Lesson Day Lesson Time Lesson Length

PARENT INFORMATION

*Parent Name(s):

*Email Address (1):

Email Address (2):

*Phone (1):

Phone (2):

*Home Address:

Special Needs for Student(s):

*Signing below indicates that the above information is correct*

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 29, 2022 3:46 am MST

Student Profile Uploaded by Mike Kaminski - office@evsm.net IP 70.163.125.146