Student Profile Form

Please fill out and submit this form if you are new to SSC and are interested in Private Lessons or are requesting a teacher change.

This form will go directly to the Director of Private Instruction who will contact you at her earliest convenience.

Please Note: This form does not reside on a secure server. You may still use this form or you can Download a Word document of our Student Profile Form to email or mail to us. No financial information is requested in this form.

 

Student's First Name* A value is required.Minimum number of characters not met.
Student's Last Name* A value is required.Minimum number of characters not met.
Student's Date Of Birth or "Adult"* A value is required.Minimum number of characters not met.
Parent/Guardian's First Name
(if applicable)*		 A value is required.Minimum number of characters not met.
Parent/Guardian's Last Name
(if applicable)*		 A value is required.Minimum number of characters not met.
Street Address/P.O. Box* A value is required.Minimum number of characters not met.
City/Town/State* A value is required.Minimum number of characters not met.
Zip Code* A value is required.Minimum number of characters not met.
Primary Phone* A value is required.Minimum number of characters not met.
Secondary Phone* A value is required.Minimum number of characters not met.
School (if applicable)* A value is required.Minimum number of characters not met.
Grade (if applicable)* A value is required.Minimum number of characters not met.
Email Address* A value is required.Minimum number of characters not met.
Emergency Contact's Name* A value is required.Minimum number of characters not met.
Emergency Contact's Phone* A value is required.Minimum number of characters not met. 
*Required field

 

 
 
  
Instrument/s or voice
Campus: (check one or both) Hingham Duxbury
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
Monday Tuesday Wednesday Thursday Friday Saturday (limited)

May we have permission to use photographs of your child for publicity purposes?


How did you hear about South Shore Conservatory? (required field)

Please make a selection.