New Student Intake Form
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Student Full Name
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Parent Full Name if Student is a Minor.
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Student Birthdate
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Phone Number
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Email
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Does the student have any allergies or dietary restrictions?
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Some lesson plans include rewards for consistent practice and accomplishments. What types of rewards is the student allowed able to have?
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Any Candy
Small Toys
Only Sugar Free Candy
Stickers
Only Kosher/Halal Options
Craft Rewards (ex. playdoh, glowsticks, etc.)
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Does the student have any preferred songs or genres they would like to learn?
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What are your goals in regard to lessons?
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Are there any learning or other disabilities that you would like me to be aware of in order to best accommodate the student? If we have already discussed this, you can leave it blank.
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Please type your full name below to serve as an electronic signature stating that you have read and agree to our Cancelation/Liability Policy.
Tuition is due by the first lesson of each month. If fewer than four lessons are scheduled in a month, tuition will be prorated. In months with five weeks, the fifth lesson is complimentary and will not be made up if missed. If a lesson needs to be canceled with at least 48 hours’ notice, it may be rescheduled or credited toward the following month’s tuition. Any lessons canceled by the teacher will always be credited or rescheduled. Same-day cancellations are not guaranteed and won’t be prorated. Life happens! Please let me know of any schedule changes as soon as possible and I will do my best to accommodate changes whenever possible. Students can expect to purchase lesson books approximately every 6–9 months depending on individual pacing and will generally cost around $30 per level. I will provide any additional music that is recommended outside of the lesson books. You agree to release Braelyn Heltne and Heltne Piano of any and all liability and agree that you understand that public recitals and events will be filmed and photographed. If you have any privacy requests regarding use of photos/videos taken at recitals and events, you agree to let us know via text or email ahead of time and all reasonable steps will be taken to accommodate them.
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