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Music Lesson Registration Form

Thank you for your interest in enrolling your child at Dixon Hall Music School (DHMS). Required fields are followed by * Registration requirements:

1. Your child must live between Jarvis St. and Broadview Ave. and Gerrard St. E and the Gardiner Expressway.

2. You must provide proof of income along with your completed registration form.

Completed and signed registration forms can be returned to DHMS or emailed to lynette.gillis@dixonhall.org. You can apply for up to four children per form. For a complete list of programs or to register online, visit www.dixonhall.org.

PARENT / GUARDIAN INFORMATION:

Mr.Mrs.Ms.
First Name*:
Last Name*:
Mr.Mrs.Ms.
First Name:
Last Name:
Street (Apt #)*:
City*:
Postal Code*:
Primary Phone #*:
Secondary Phone#:
Email Address:

Bills will be sent electronically to your email address, if provided.

Do you give Dixon Hall permission to use photos/videos of your children for promotion purposes*? YesNo
How did you hear about Dixon Hall Music School?
Have your children taken lessons here before?*
YesNo

LESSON FEES & PAYMENTS:

All lesson fees are subsidized and are based on family income and number of dependents. Under ‘Income Type,’ please indicate whether your income is from a work salary, family benefits, child support payments or any other source. This information is kept confidential. Please provide proof of reported income (i.e. pay stub, benefits statement, T4).

If your total income is less than $42,000 you will need to show proof of income (i.e. pay stub, benefits statement, T4) at your first lesson.

Payments are to be made at the beginning of each term (fall, winter, spring, summer) or on a monthly basis. Both cash and/or cheques made out to Dixon Hall Music School are accepted.

Family Member Name*:
Income Type*:
Monthly Income*:
Family Member Name:
Income Type:
Monthly Income:
Total Family Income per year*

STUDENT INFORMATION: CHILD #1* (please complete all fields)

First Name:
Last Name:
Age:
Birthday :
Email:
Cell Phone #:
Which instrument/class are you applying for?
Does your child take lessons anywhere else? YesNo
If yes, where and for which instrument?
Are there any medical or behavioral conditions we should be aware of? i.e. allergies, ADHD, asthma, etc.
Check one: I need to rent an instrumentI own my instrumentI currently rent an instrument

STUDENT INFORMATION: CHILD #2

Contact information is the same for each child Note
First Name:
Last Name:
Age:
Birthday:
Email:
Cell Phone #:
Which instrument/class are you applying for?
Does your child take lessons anywhere else? YesNo
If yes, where and for which instrument?
Are there any medical or behavioral conditions we should be aware of? i.e. allergies, ADHD, asthma, etc.
Check one: I need to rent an instrumentI own my instrumentI currently rent an instrument

STUDENT INFORMATION: CHILD #3

First Name:
Last Name:
Age:
Birthday:
Email:
Cell Phone #:
Which instrument/class are you applying for?
Does your child take lessons anywhere else? YesNo
If yes, where and for which instrument?
Are there any medical or behavioral conditions we should be aware of? i.e. allergies, ADHD, asthma, etc.
Check one: I need to rent an instrumentI own my instrumentI currently rent an instrument