Register #8802 - vancomusic

Registration Form

I am a:

Parent / Guardian

Student Information

First name:

Haana

Last name:

Nasiri

Date of Birth:

2010-11-16

Parent Information

First name:

Soheila

Last name:

Sahragard

Parent / Guardian's Email:

soheila.srd1@gmail.com

Contact Number:

17789821717

Relationship to student:

Mother

Address

Country:

Canada

City:

Coquitlam

State / Province / Region:

Bc

Address Line 1:

3097 Lincoln Ave

Address Line 2:

ZIP / Postal Code:

V3B 0E3

Program Selection

I am looking for:

In-person Lessons

What level would you like to register?

Level 1-4

Please write the program or instrument you are interested in:

Piano

How many days a week would you like to have classes?

Once a week

Which days are you available for lessons?

Monday, Wednesdays, Thursdays

We'd love to know how you heard about us:

Word of Mouth

Referrer: