Music Instruction Signup

Please fill out this form with your contact information.
If you have any questions you can reach us at (717) 653-9511 or at smc@raise28.org

Student's Name

Age & Grade Level (separate by comma)

Parent/ Guardian Name (First, Last)

This address will receive a confirmation email

Phone

Which instrument(s) is the student interested in?

Please select all that apply.

Guitar (open) Piano (waitlisted) Ukelele (waitlisted) Drums (waitlisted) Music Recording Technology (waitlisted)

If multiple instruments selected above, which is the primary interest?

Please select one option.

Guitar Piano Ukelele Drums Music Recording Technology

Does the student own their own instrument? (Note- Note- RAISE28 may offer an instrument for temporary on-site use, which is limited to availability. Students are strongly encouraged to purchase personal equipment for at-home practice.)

Please select one option.

Yes No

What is the student's experience level on the instrument?

Please select one option.

Never Played Beginner (0-12 months) Intermediate (1-3 years) Advance (3+ years)

Does the student have any learning needs or accommodations?

Preferred Lesson Day(s)

Please select all that apply.

Mon Tue Wed Thu Fri Sat

Would you like to hear more about our free student afterschool and summer programs?

Please select one option.

Yes, please! No, thank you. My child(ren) already participate(s).

If you answered "yes" above, what are the first names & ages of your children? (separate with commas)

Description

Please fill out this form with your contact information.
If you have any questions you can reach us at (717) 653-9511 or at smc@raise28.org

Music Instruction Signup

Description

Please Fix the Following