Name: *


Age: *


If under 18, Parent name: *


Address *


City *


Home phone: *


Cell phone: *


Email: *


Best contact number in case of an emergency: *


Main Instrument/Singer: *


Other instruments played: *


Teacher (if currently taking lessons): *


Do you sing?lead? backgrounds? *


Years playing/singing: *


Styles (artists) of music played (by order preference): *


Reading ability (tab, notation, chord chart, rhythm charts, etc): *


Medication Allergies


Food Allergies


Other Allgeries( insect, etc.)


Diabetes
Y/N N Y

Seizures
Y/N N Y

Asthma
Y N Y/N

ADD/ADHD
Y N Y/N

Obsessive-Compulsive-Disorder
Y/N N Y

Short and Long Term Memory Problems
Y/N N Y

Week
July 18-23rd
Aug 1st -6th
Both