Parent/Guardian Info

Name

Street Address

City

Daytime Phone

Cell Phone

Email



Student Info

Student

Name

Age

Instrument
 Piano Guitar Drums Bass Voice Other

Level
 Beginner (0-1 year of lessons) Intermediate (2-3 years of lessons) Advanced (3+ years of lessons)

Second Student

Name

Age

Instrument
 Piano Guitar Drums Bass Voice Other

Level
 Beginner (0-1 year of lessons) Intermediate (2-3 years of lessons) Advanced (3+ years of lessons)

Third Student

Name

Age

Instrument
 Piano Guitar Drums Bass Voice Other

Level
 Beginner (0-1 year of lessons) Intermediate (2-3 years of lessons) Advanced (3+ years of lessons)

Fourth Student

Name

Age

Instrument
 Piano Guitar Drums Bass Voice Other

Level
 Beginner (0-1 year of lessons) Intermediate (2-3 years of lessons) Advanced (3+ years of lessons)



What Programs Are You Interested In?

 InHome Lessons

 Group Lessons KidzBandz WeeMix (ages 3-4) FamJamz Mom-Dad RockJamz



Preferred Days/Times

Please give a range so we can best accommodate your request.
(eg: M 3-4, W 2-6, F 3-4)



How Did Your Hear About IHJ?

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Please tell us how you heard about us.