Kids & Teen Private Lesson – Returning Student

Student Information

Student Name*

Date of Birth*

Age*

Parent / Legal Guardian Information

Parent / Legal Guardian Name*

Address*

City*

Postal Code*

Telephone*

Cell*

Work Phone

Email Address*

Emergency Information

Emergency Contact Name*

Emergency Contact Telephone*

Emergency Contact Cell*

Health Information

Known Allergies / Health Information

2. ITALIAN LANGUAGE EXPERIENCE

Has the student studied Italian before?*
NoYes

If yes, for how long?

How would you describe current level?*
Complete BeginnerBeginnerElementaryIntermediateAdvanced

Payment & Terms
Private lesson fee: $100 per 1-hour session.

Agreement
By signing this form, you agree to all the terms indicated above.

Student or Parent/Legal Guardian Signature (Type Full Name)*

Date*