IAM Registration Form

Imperial Academy of Music

Student Registration Form
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Guardian*

First NameLast Name
Email*
example@example.com
Address (Required for In-Home Lessons)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prefered Days?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Prefered Times:*

10am-12pm12pm-3pm3-6pm6pm-9pm
I would like my lessons:*

OnlineIn-StudioIn-Home
Lesson(s) of Interest:*

DanceActingPianoGuitarSong WritingSong & Dance (5-7)Impulse(Group Acting: 9-13)Step In Time (Professional Development)
I prefer to pay:*

MonthlyBi-MonthlyPer Class (+$5.00)
Picture/Video Release Form

I,   First Name   Last Name   , (guardian) of   First Name   Last Name   [Child] grant Imperial Academy of Music my permission to use the photo/video footage for any legal use, including web content, marketing and advertising.
Parent/Guardian’s Signature:   Signature
Date:   Date
Anything we should know about our new student? Let us know!
Should be Empty:

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Imperial Academy of Music