Pumpkin Club Piano Academy
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Pumpkin Club Atlanta

新メンバー登録 - New Member Registration

/
生徒(Student)

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:
E-mail:
Home Phone (自宅):
Cell Phone (携帯):

Student Cell Phone (生徒の携帯):

住所 - Address

  City State Zip

ピアノを習った経験は?
Have you ever taken piano lessons?
(Non-member only)

ピアノ以外の楽器の経験は?
Other instrument you play:

右の音楽イベントに参加希望の場合はチェックマークを記入してください。
Please check the event(s) you would like to participate in.

Music Teachers Association Audition

Federation Music Festival

写真やビデオを当ウェブサイトやYouTubeに載せることを希望されない場合はチェックしてください。
Check here if you do NOT want to publish your pictures/videos on our website/YouTube.

ポリシー同意書を読み、理解しました。(同意書は必ずお読みください)
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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