Student Name *

First Name

Last Name

Date of birth *

Please note this date is in American format of month/day/year

MM

DD

YYYY

Parent or Guardian name

If you're under 18

First Name

Last Name

My preferred days for lessons *

We'll try to be flexible, which days work best for you?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

I wanna play every day

Where did you hear about Rock Scholars?

A friend told me

Google

Radio or TV ad

Facebook

I got a voucher for a lesson

Hyper music lesson offer

Some other way