Western Illinois University: Macomb Campus

Student Information

Student Name:

Student Age:

Home Address:

Home Phone:

Parent Information

Parent/Guardian Name(s):

Mother's Phone:

Mother's Work Phone:

Mother's Email:

Dad's Phone:

Dad's Work Phone:

Dad's Email:

Emergency Contact Information

Name:

Relationship:

Cell/Phone:

Experience

Please describe any previous piano experience your child has had (teacher(s), books used, years of study, etc.):

Please describe the practice environment your child will have access to on a daily basis (type of piano/keyboard, location of piano/keyboard, number of keys if using a keyboard):

Choices

Please list your top three choices for lesson days/times:

Choice 1:

Choice 2:

Choice 3:

Note

Lessons are pro-rated at $30/hour:

• 30 minute lessons - $15
• 45 minute lessons - $22.50
• 60 minute lessons - $30

Please carefully review the Piano Program Handbook, available online, for additional information, policies and important dates: Community Music School.

Parent Instructions and Confirmation

Check here if you do not give permission for pictures or name of student to be used for publicity in publications such as, but not limited to, newsletters, newspapers and magazines, and WIU brochures.

Parent signature for permission to enroll.

Date:

Registration Information

Checks payable to: Community Music School

Please make your checks payable to "WIU Community Music School" and give payment directly to the director at the first rehearsal of the semester OR mail check to:

Richard Cangro, CMS Director

Western Illinois University

1 University Circle

Macomb, IL 61455