Private Lessons Registration Form

* Indicates required field

Student's Name *

First

Last

Student's Age *

Student's Date of Birth *

What are you registering for? *

Instructor's Name *

Parent/Guardian Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Emergency Contact Name *

First

Last

Emergency Contact Relationship to Student *

Emergency Contact Phone Number *

How did you hear about this class at Gene Nastri School? *

The school is hereby granted permission to take photographs and videos of the students to use in brochures, web sites, posters, advertisements and other promotional materials the school creates. Permission is also hereby granted for the school to copyright such photographs in its name.

I Agree to the Photo Release *

Yes No

Type Your Name (Signature of Parent/Guardian or Adult Student) *

Click on "Register Now" to complete your registration.

I agree to receiving marketing and promotional materials *