Name: _______________________________________________________________________

Address: _____________________________________________________________________

_____________________________________________________________________________

E-Mail: ______________________________________________________________________

Home Telephone: _______________________ Cell Telephone: ________________________

Type of keyboard/piano at home: __________________________________________________

Please indicate below the length of lesson requested and which weeks you are available for lessons. To the right of each week is a place for comments, requests, conflicts, etc. (Example: "I am free any time this week except Wednesday after 2:00 pm", or "any day but Friday") PLEASE BE SURE TO LIST ANY AND ALL CONFLICTS. (The more details you can give, the easier it will be to schedule.) Also, please know that spreading out your lessons throughout the summer is more beneficial than having them all in one month. Thanks!

_____ 30 minutes @ $22 _____ 45 minutes @ $33 _____ 60 minutes @ $44

_____ June 1-3 _______________________________________________________________

_____ June 6-10 _______________________________________________________________

_____ June 13-17 ______________________________________________________________

_____ June 20-24 _____________________________________________________________

_____ June 27- July 1 __________________________________________________________

_____ July 5-8 (no classes Mon., July 4) ____________________________________________

_____ July 11-15 ______________________________________________________________

_____ July 18-22 ______________________________________________________________

_____ July 25-29 ______________________________________________________________