Pacific Piano School Online Registration

Registration

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Welcome to Pacific Piano School! We are thrilled to have you as part of our musical family! Please complete the following registration form and we will reach out to you to welcome you, confirm available times, answer your questions, and make recommendations on how to get the most out of Pacific Piano School.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

School

Grade Level

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

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

Required Policies

(Show-Hide Details)