APPLICATION FORM
HOW TO COMPLETE THIS FORM: EITHER copy, complete and email to Dulais Rhys: dulaisrhys(at)ymail(dot)com OR print off, complete and mail to Dulais Rhys (postal address on request)
APPLICATION FOR PIANO EDUCATION
This information will only be used for its intended purpose, will be treated in strict confidence and will not be
passed on to a third party.
* = circle one or delete as necessary
1.1 APPLICANT FIRST NAME(S):
LAST NAME:
1.2 APPLICANT (if under 18) NAME OF PARENT(S):
2. APPLICANT (if under 18) DATE OF BIRTH:
3. HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
4.1 TELEPHONE(S): HOME:
CELL:
4.2 E-MAIL:
4.3 WHAT IS YOUR PREFERRED METHOD OF COMMUNICATION? Home Phone*Cell Phone*Email
5. WILL INSTRUCTION BE NEEDED ‘FROM SCRATCH’? Yes*No (If ‘Yes’, go to 8.)
Section 6. does not have to be answered
6.1 HOW MANY PREVIOUS PIANO TEACHERS HAVE YOU HAD?
6.2 REASON(S) FOR DISCONTINUATION OF PREVIOUS TUITION:
7. PIANO EXAMINATION(S) PASSED:
Date:
Details etc.
8. WHAT KIND OF PIANO DO YOU HAVE AT HOME?
9. MUSICAL OBJECTIVE: WHAT DO YOU HOPE TO ACHIEVE?
For example: Play for Pleasure*Prepare for concert/recital etc.*Prepare for examination etc.
*Other (please specify):
10. WHEN WOULD YOU LIKE THE INSTRUCTION TO START?
As soon as possible*A certain date (please specify):
11. PLEASE RANK (1st choice top) YOUR PREFERRED LESSON DAY(S) AND TIME(S):
Monday*Tuesday*Wednesday*Thursday*Friday*Saturday*Sunday* TIME(S): Monday*Tuesday*Wednesday*Thursday*Friday*Saturday*Sunday* TIME(S): Monday*Tuesday*Wednesday*Thursday*Friday*Saturday*Sunday* TIME(S): Monday*Tuesday*Wednesday*Thursday*Friday*Saturday*Sunday* TIME(S):
12. WHAT LENGTH OF LESSON WOULD YOU PREFER? 30mins*45mins*60mins*I need advice
13. ANY ADDITIONAL INFORMATION? QUESTIONS? SPECIAL NEEDS?
(e)Signature:
Date:
Thank you for your time in completing this form.
Please return to Dulais Rhys as soon as possible – see instructions at the top of this form.