Burbank Music Academy Online Registration

BMA is the PREMIER music lesson facility in the area. We provide quality instruction in most instruments (Piano, Voice, Violin, Guitar, Drums, Flute, Clarinet, Saxophone, Ukulele, Bass Guitar, & More). PLEASE COMPLETE the registration form to get started. Once we receive this information, we will reach out to you to get your payment information and get a time slot selected.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family (Students Lname) Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Work #

Cell #

Email* (Emails are kept confidential)

Confirm Email*

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Work #

Cell #

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Instrument Choice #1

Instrument Choice #2

In Person or Remote

Preferred Pronouns

Preferred Days:M/Tu/W/TH/F/Sa

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Instrument Choice #1

Instrument Choice #2

In Person or Remote

Preferred Pronouns

Preferred Days:M/Tu/W/TH/F/Sa

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Instrument Choice #1

Instrument Choice #2

In Person or Remote

Preferred Pronouns

Preferred Days:M/Tu/W/TH/F/Sa

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Instrument Choice #1

Instrument Choice #2

In Person or Remote

Preferred Pronouns

Preferred Days:M/Tu/W/TH/F/Sa

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Student Email

School

Grade Level

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Instrument Choice #1

Instrument Choice #2

In Person or Remote

Preferred Pronouns

Preferred Days:M/Tu/W/TH/F/Sa

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Required Policies

(Show-Hide Details)