Epitelo Music Academy

Teaching music to every child

Lesson Application

Click here for the application form, or fill it out below. Basic InformationStudent Name: Birthdate: Parents' Names: Email Address: Street Address: Home Phone: Cell Phone: How did you hear about us?

Musical Information

Instrument: If there is more than one teacher for your instrument, which teacher would you like? Has the student played this instrument before?
Yes
No
If yes, where? How long has the student played? Has the student taken private music lessons before?
Yes
No
Can the student read music?
Yes
No
Has the student taken music theory?
Yes
No
How did the student first become interested in this instrument?
Does the student have any learning disabilities that may hamper his/her ability to study the instrument?
Yes
No
If yes, what? Does the student have any physical disabilities that may hamper his/her ability to study this instrument?
Yes
No
If yes, what? Do you have any other concerns about the student's ability to study this instrument, or other comments or questions about lessons?
What day is your FIRST choice for lessons? What other days are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time of day would you like the lesson? How long would you like the lesson? +This is only available for kids ages 5 - 7 or those who take theory classes.Are you interested in theory classes or computer theory?
Yes, computer theory
Yes, classes
Yes, both
No
Would you like to sign up for the mailing list, to receive special offers, notices, and the monthly newsletter?
Yes
No
I have filled out this form to the best of my abilities, and I have read and agree to the studio policies.
Yes
No

Epitelo Music Academy. 4620 Dolomite Ct., Columbus OH 43230. (614) 625-1064. Kate@epitelomusic.com.