Pumpkin Club Piano Academy
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Pumpkin Club Atlanta

新メンバー登録 - New Member Registration


名前 - Name:

性別 - Gender:

男 - Male   女 - Female
生年月日(年齢) - D.O.B. (Age): 月/日/年 / / ( )
保護者 (Parents / Legal Guardians)
名前 - Name:
Home Phone (自宅):
Cell Phone (携帯):

Student Cell Phone (生徒の携帯):

住所 - Address

  City State Zip

Have you ever taken piano lessons?
(Non-member only)

Other instrument you play:

Please check the event(s) you would like to participate in.

Music Teachers Association Audition

Federation Music Festival

Check here if you do NOT want to publish your pictures/videos on our website/YouTube.

I have read and agreed the payment term and the academy policy. (click to read)

* All fields are required

We will never give or sell your information to any third party.
Also your information will not keep in our web server computer as database.

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