Brandywine Music/Piano Studio

Piano Lessons, Music for Special Occasions

 Umile Music Piano Program

Registration Form/Parent-Teacher Agreement

2017 – 2018 School Year


Student’s Name (1) ____________________________Birthdate___________Grade in school_____

Student’s Name (2) ____________________________Birthdate___________Grade in school_____

Parents’ Names________________________________________________________


Cell Phone (parent who will usually bring student)______________________

Cell Phone (other parent)______________________Home Phone_________________

Email address(es)_______________________________________________________

Preferred method of communication:  Email___Phone call___Text___


Student’s music experience(1)___________________Student(2)__________________

Parent’s music experience_________________________________________________

Do you have a: piano (acoustic)___Tuned/in good repair?_____

Digital piano___full-size___weighted keys___ Keyboard (non-weighted)___# of keys___

Referred by/how you found me____________________________________________


Style(s) of music instruction desired (check all that apply):  Suzuki___Traditional___

Rigorous classical___Relaxed pop___Other (specify)_________________________


Please describe any learning style/difference/disability that I should be aware of (ex.:

visual learner, auditory learner, very active, very shy, physical impairment, dyslexia,

AD/HD, autism) or serious allergy  (1)_____________________________________  




___Please check here if you do NOT consent to photos or videos of your child to be posted

on the Internet or used in promotional materials. (Children’s full names are not used.)


HOURS: Mon. - Thurs. 1:00 – 8:00 pm; Fri. 3:00 – 6:00 pm

Please specify your day and time availabilities: _______________________________________



TUITION FEE DEPOSIT:  $50/single student, $75/family, due at first registration and each July 1.

 (See Membership/Tuition page) This will apply towards your first quarter tuition.


I agree to the terms and policies of this studio and agree to indemnify, release and hold harmless

Diana L. Umile or her associates from any claims or causes of action arising or related in any respect

to the activity or the child’s participation in such activity.


Parent’s Signature_____________________________________________Date_____________