Student Profile Form

Please fill out and submit this form if you are new to SSC and are interested in Private Lessons or are requesting a teacher change.

Please Note: This form does not reside on a secure server. You may still use this form or you can Download a Word document of our Student Profile Form to email or mail to us. No financial information is requested in this form.

 

Student's First Name* A value is required.Minimum number of characters not met.
Student's Last Name* A value is required.Minimum number of characters not met.
Student's Date Of Birth or "Adult"* A value is required.Minimum number of characters not met.
Parent/Guardian's First Name
(if applicable)*		 A value is required.Minimum number of characters not met.
Parent/Guardian's Last Name
(if applicable)*		 A value is required.Minimum number of characters not met.
Street Address/P.O. Box* A value is required.Minimum number of characters not met.
City/Town/State* A value is required.Minimum number of characters not met.
Zip Code* A value is required.Minimum number of characters not met.
Primary Phone* A value is required.Minimum number of characters not met.
Secondary Phone* A value is required.Minimum number of characters not met.
School* A value is required.Minimum number of characters not met.Exceeded maximum number of characters.
Grade* A value is required.Minimum number of characters not met.
Email Address* A value is required.Minimum number of characters not met.
Emergency Contact's Name* A value is required.Minimum number of characters not met.
Emergency Contact's Phone* A value is required.Minimum number of characters not met. 
*Required field

 

 
 
  
Instrument/s or voice
Campus: (check one or both) Hingham Duxbury
Previous experience on instrument:

 

Other musical experience: (choir/band/orchestra etc)
Other interests
What kind of teaching style do you think will work for you/your child?
What are the goals/ambitions of the student?
Is there anything else you think we should know in order to effectively place this student? (learning style/special needs, gender preference, etc)

 

Please check off available days
Monday Tuesday Wednesday Thursday Friday Saturday (limited)

Would you like to receive a schedule of the Discounted Basic Musicianship classes?
($25 for 6 one hour classes)

May we have permission to use photographs of your child for publicity purposes?


How did you hear about South Shore Conservatory? (required field)

Please make a selection.