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Melodic Rhythms Lesson Form

Student's Name:*


Parent's Name: (if minor)


Email Address:*


Address:*

Street Address

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Home Phone Number:*
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Cell Phone Number:
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Instrument:*


Instrument Experience:*


Student's Age:*


What are you interested in signing up for? Check all that apply:*
Private Lessons Group Lessons Mini Melodies The Academy Tutoring

Are you a current student or have you ever been a student at Melodic Rhythms?*
Yes (Current Student) No Yes, I was a previous student (from when to when?)

Location Desired:*
Belleville Breese SKYPE

Lesson times requested and General comments:*

Melodic Rhythms 110 North High Street, Belleville IL 62220 * 618-233-0659 * 560 North 2nd Street, Breese, IL 62230 * 618-526-7588 * www.melodicrhythms.com
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