Student Name *

First Name

Last Name

Date of birth *

Please note this date is in American format of month/day/year

MM

DD

YYYY

Parent or Guardian name

If you're under 18

First Name

Last Name

Where did you hear about Rock Scholars?

A friend told me

Google

Radio or TV ad

Facebook

I got a voucher for a lesson

Some other way

I give permission for photographs of my child to be used in Rock Scholars print media, newsletters, website or social media

Yes

No