Adapted Learning Music Program Registration

Parent/ Guardian Information

Parent/Guardian #1*

Prefix

First Name*

Last Name*

Parent/Guardian #2

Prefix

First Name

Last Name

Address*

City*

Postal Code*

Primary Phone*

Email address

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

Preferred Method of Contact*

Phone

Both

Secondary Phone

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

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

Child Information

First Name*

Last Name*

Age*

Birthday*

DD/MM/YYYY

Pronouns*

Student Phone

Only if they have their own cell phone

Student Email Address

Only if they have their own 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

If yes, please specify who:

Payment Information

Lesson costs will be set on an individual basis.

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

Yes

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:

Submit

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

I agree

This field should be left blank

Parent/ Guardian Information

Child Information

Lesson Information

Payment Information

Additional Information (Optional)

Submit

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