Student Profile Form

Please contact Hingham Placement Coordinator Jessica Wilcox at 781-749-7565, ext. 37 or
Duxbury Campus Manager Nancy Meredith at at 781-934-2731 x11 for assistance.

You may also Download a PDF of our Student Profile Form to email or mail to us.

Student Name:*

Student's Date Of Birth or "adult"*

Parent/Guardian's First Name (type "adult" if you are an adult)*

Address:*
Primary Phone:*

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Secondary Phone:*

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School and grade (if applicable):*

E-mail:*
Emergency Contact's Name*

Emergency Contact's Phone*

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Instrument/s, Voice or Drama

Campus: (check one or both)
Previous experience on instrument:
Other musical experience: (choir/band/orchestra etc)
Other interests
What kind of teaching style do you think will work for you/your child?
What are the goals/ambitions of the student?
Is there anything else you think we should know in order to effectively place this student? (learning style/special needs, gender preference, etc)
Please check off available days
What would be the earliest time you could start a lesson on your available days?

What would be the latest time you could start a lesson on your available days?

May we have permission to use photographs of your child for publicity purposes?
How did you hear about South Shore Conservatory?*

Word Verification: