(All information provided will be kept confidential)
New Student Name: *
Age: *
Please give name of person who would be paying for the music lessons (parent name /self): *
Telephone Number: *
Instrument: *
Level required: *	Beginner Intermediate Advanced Exam stream Music 'just for fun'
Best location: *	Trenton Frankford Stirling Trenton or Frankford Frankford or Stirling Trenton, Frankford or Stirling
What music tuition are you looking for?: *	Individual, private music lessons Group family lessons 'Kidz Guitar 101' Saturday camps (age 8+) Group Singing (age 8+ or 13+) Musical Theatre (Kids or Youth) Summer music camps (guitar, rock school, etc.) Workshops Other (please specify below)*
Other (*)
Is anyone in your family currently taking lessons with us at any location at RiverSide Music: *	Yes No
Specific Teacher requested (if known):
Best Days of the week that you would like music lessons (Monday to Saturday): *
Best Times for you (10am to 8pm): *
Special Needs or Requirements: *	No Yes - please contact me to discuss
E-mail address:
How did you hear about us?:	Recommendation from friend or family member Yellow Pages Local Newspaper Advert Flyer Radio Walked into store Internet search
Interested in the Quinte Community Music Groups (non profit)?:	Quinte Community Childrens Ensemble (8+) Quinte Community Youth Orchestra(13+)