Complete Student Intake Form

🎼 Complete Client Intake Form 🎼

Detailed information to personalize your learning experience

🎵 Thank You! 🎵

Your application has been submitted successfully! We'll review your information and contact you within 24 hours to schedule your first lesson.

Personal Information

Full Name: *

Age Group:

Below 55

55-64 (Senior)

65-74 (Active Senior)

75+ (Elder)

Employment Status:

Contact Information

Primary Phone:

Email Address: *

Home Address:

Preferred Contact Method:

Best times to call:

Emergency Contact

Emergency Contact Name:

Relationship:

Emergency Contact Phone:

Musical Background

Primary Instrument of Interest:

Current Skill Level:

True beginner (never played)

Returning beginner (childhood lessons)

Intermediate

Previous Musical Experience:

Specific Musical Goals:

What motivates you to learn music now?

Personal enjoyment and fulfillment

Cognitive and memory benefits

Connect with family through music

Meet like-minded people

Play for church/community service

Fulfill lifelong dream

Learning Preferences

How do you learn best?

Visual (seeing demonstrations, reading music)

Auditory (listening, verbal instruction)

Hands-on (physical practice, muscle memory)

Combination of all approaches

Preferred learning pace:

Patient and gentle

Moderate and steady

Energetic and challenging

How do you prefer to remember instructions?

Written notes and reminders

Audio recordings of lessons

Visual demonstrations

Lots of repetition and practice

Scheduling Preferences

Preferred lesson frequency:

Preferred lesson length:

30 minutes

45 minutes

60 minutes

Preferred lesson days (check all that work):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred lesson times:

Early Morning (8-10 AM)

Mid Morning (10 AM-12 PM)

Early Afternoon (12-2 PM)

Mid Afternoon (2-4 PM)

Late Afternoon (4-6 PM)

Early Evening (6-8 PM)

Lesson format preference:

In-person lessons only

Virtual/online lessons only

Mix of in-person and virtual

How flexible is your schedule?

Very flexible (can adjust easily)

Somewhat flexible

Prefer consistent weekly schedule

Health and Physical Considerations

Hearing status:

Excellent

Good

Mild hearing loss

Use hearing aids

Vision considerations:

Good vision

Use reading glasses

Need large print materials

Need bright lighting

Physical considerations that might affect playing:

No physical limitations

Arthritis in hands/fingers

Back or posture concerns

Limited stamina/need breaks

Other (please specify below)

Additional health information that would help us serve you better:

Technology and Equipment

Technology comfort level:

Very comfortable with technology

Basic technology skills

Minimal technology experience

Prefer to avoid technology when possible

Do you currently own your instrument? If so, please describe:

Describe your practice space at home:

For virtual lessons - Internet connection quality:

Excellent (high-speed broadband)

Good (reliable connection)

Fair (sometimes slow)

Poor/unreliable

Not applicable (in-person only)

Payment Information

Preferred payment method:

Personal check

Cash

Credit/Debit card

PayPal/e-Transfer

Bank transfer

Preferred payment frequency:

Per lesson

Monthly

Lesson packages (4-6 lessons)

Goals and Expectations

What would you like to accomplish in your first 6 months?

What's your long-term musical vision (1-2 years)?

How much time can you realistically commit to practice?

15 minutes daily

30 minutes daily

45 minutes daily

Weekends mainly

Irregular schedule

Interest in performance opportunities:

Family gatherings

Church/community events

Student recitals

Group performances

Personal enjoyment only

Additional Information

How did you hear about our music instruction?

Would you be interested in group lessons with other senior students?

Yes, very interested

Maybe, depending on the group

No, prefer individual lessons

Would you like family members involved in your musical journey?

Progress updates to family

Invite family to recitals

Family practice support

Keep this as my personal journey

Any special requests, concerns, or information we should know?

Permissions (check all that apply):

Permission to record lessons for your practice

Permission to take photos at recitals/events

Permission to use testimonials for marketing

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🎼 Thank You for Your Detailed Information! 🎼

This comprehensive information helps us create a personalized learning experience just for you. We'll review your responses and contact you within 24 hours to schedule your first lesson and discuss any questions you might have.

Ready to begin your musical adventure?

🎵 Making Music at Every Age 🎵

Questions? Call us at (416) 574-3871 or email play@musicably.com