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Adapted Learning Music Program Registration

Page 1 of 6

Parent/ Guardian Information

Parent/Guardian #1*

First Name*

Last Name*

Parent/Guardian #2

First Name

Last Name

Address*

City*

Postal Code*

Primary Phone*

Secondary Phone

Email address*

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

Preferred Method of Contact*

Phone

Email

Both

Language(s) spoken at home*

How did you hear about Dixon Hall Music School?

Do you give Dixon Hall permission to use photos/videos of your children for promotional purposes?*

Yes

No

How many children are you enrolling in Dixon Hall Music School?*

Child Information

First Name

Last Name

Gender

Optional to provide pronouns: She/Her, He/Him, They/Them, etc.

Age

Birthday

Student Phone

Student Email Address

Any known physical, intellectual, or developmental disabilities?*

Does your child have any physical health (allergies, etc.) conditions that could impact learning?

Main mode of communication:

Verbal

Visual Supports

Sign language

Digital Devices

General interests and strengths of the student:

Lesson Information

Goals for the lessons: *

(why are you registering your child(ren) for adapted music lessons with DHMS?)

Instrument:*

Violin

Piano

Ukulele

Guitar

What are your child’s musical preferences? (genres, singers, artists, instruments, etc.)*

DD/MM/YYYY

Check one:*

I need to rent an instrument

I own my own instrument

I currently rent an instrument

Does your child take music lessons currently, or has studied music in the past? If yes, where and for which instrument?*

Will a parent/guardian/support worker be attending lessons with the student? *

Yes

No

If yes, please specify who:

Payment Information

Will you be paying for Adapted Lessons with, or with the assistance of, funding provided for your child?

Lesson costs will be set on an individual basis.

Yes

No

If yes, please list the type of funding you are receiving, along with any other pertinent information:

Additional Information (Optional)

When my child gets upset, he/she will:

My child needs some prompting to maintain attention or take turns. The best things to do are:

If my child needs the restroom, he/she will communicate by:

I know my child needs a break when:

Some additional info that could be helpful to know:

By submitting this registration form, I agree to receiving Dixon Hall Music School updates and information

I agree

This field should be left blank

Charitable Registration Number:
11888 6308 RR0001

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