Brandywine Music/Piano Studio

Piano Lessons, Music for Special Occasions

Brandywine Music Piano Program

Registration Form/Parent-Teacher Agreement

2018 – 2019 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___Text message___Phone call___


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

Parent’s music experience_________________________________________________

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

OR: 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):  Traditional___Suzuki___

Rigorous classical___Recreational pop___Variety___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)_____________________________________  


Management suggestions________________________________________________



___Please check here if you do NOT consent to your student’s use of electronic apps/games 

___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. (Students' full names are not used.)


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

Please specify ALL of your day and time availabilities: __________________________________



TUITION FEE DEPOSIT:  $50/one student, $75/2 students, $100/3 or more students, due at first registration (unless full tuition paid) and each July 15. (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_____________