Personal Details

Title Mr Mrs Miss Ms Dr Prof Other

Parent's name *

Contact telephone number *

Contact person e-mail address *

A copy of your form submission will be sent to this email address.

Child's name *

Date of birth *

DD/MM/YYYY.

School from September 2019 *

Year Group from September 2019 * Pre-school Reception Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13

Special Educational Needs/Disabilities

Lesson Request

Preferred Instrument No Preference

Woodwind Flute Clarinet Saxophone Oboe Bassoon

Brass Baritone Cornet Euphonium French Horn Tenor Horn Trombone Trumpet Tuba

Strings Violin Viola Cello Double Bass Guitar Ukulele

Miscellaneous Piano Keyboard Singing Drum Kit Orchestral Percussion

Is your child currently having lessons on this instrument? * Yes No

If the answer is Yes, please provide more information below. Please include length of time learning, current Stage/Grade level and the name of the previous teacher.

Area Location * Chichester Crawley Haywards Heath Horsham Worthing

Following your initial enquiry with us, we will call you to discuss what tuition we can offer. We will aim to make contact during our office hours of 8.30am - 5pm. If there is a more suitable time for you, please make us aware below.

Where did you hear about West Sussex Music? Search engine School or college Advert Recommendation Other

If you heard about West Sussex Music from a different source then please enter it in the 'Other source' field.

Other source

To avoid our messages going into your junk folder please add music@westsussexmusic.co.uk

Data Protection

Please tick to confirm that you have read our Data Protection Policy (GDPR 2018) * I agree to the Data Protection policy.

This notice explains why we collect personal information about our customers and how we use it. Please confirm that you have read our privacy notice and understand how we will use your personal information. * I have read the Privacy Notice.

Contact Permission

From time to time, we would like to send you details of relevant musical opportunities for example concerts, excursions, and events or ways to support us which may be of interest to you. * Yes please, I'd like to hear about these opportunities. No thanks, I don't want to hear about these opportunities.

Declaration

You must be over 18 to apply for our services and you must have legal responsibility for the child named in this application. * I confirm that I am the parent/carer of the child named in this application and that I am over 18 years of age.

ELECTRONIC SIGNATURE BOX OF APPLICANT *

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