Student Name*

Student Age*

Parent or Guardian Name*

Address*

City*

State*

Zip Code*

Email*

Primary Phone Number*

Alternate Phone Number

Preferred method of contact:
PhoneEmailEither

Are you Left-handed or Right-handed?
Left-handedRight-handed

Do you currently own a guitar?*
YesNo

If so, what kind(s)?
AcousticElectricAcoustic/ElectricBass

Have you taken guitar lessons?*
YesNo

Do you play another instrument?*
YesNo
If so, which instrument(s)?

Which city or cities are you available for lessons?*
McHenryCrystal LakeWoodstockHarvardMarengo

If you selected multiple cities, which is your preferred choice?*
McHenryCrystal LakeWoodstockHarvardMarengo

Which would be provided as proof of low-income status?*
Free/Reduced Lunch StatusLink CardSSI CheckOther
If Other, what would it be:

Are you in:
Middle schoolHigh school

Can we use your photo for promotional use (on our website/marketing materials?
YesNo

How were you referred you to us?

Referral contact name:

* - Required fields