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Name:
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Address:
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City
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Postal Code
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E-mail Address:
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Home Phone Number:
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Cell Phone Number:
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Adult Student: (Age)
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Student #1: (Age)
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Student #2: (Age)
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Student #3: (Age)
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Instrument Desired: Piano, Violin, Cello, Guitar (type), Harp, Flute, Voice, Drums, Saxophone, Ukelele
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Years of Experience or None
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Desired Outcome of Lessons - RCM Exams Or Fun
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Desired Start Date:
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Instrument - Owned/Looking to Buy
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Available for Free Lesson on... (Please provide 3 days and times)
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Where did you hear about us? Google Search, DoReMi, Kijiji, Referral
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Note: Please include ONLY the ages of those interested in taking lessons. (N/A FOR BLANK)
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