Lesson Placement

I Would Like to Enroll In...(Required)

Please choose the program for which you are starting the enrollment process.

Student Information

Please fill out the following form to begin the registration process.

First Name(Required)

Last Name(Required)

Grade

School

Age(Required)

Ethnicity

Birth Date(Required)

Gender

Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Parent Phone

Second Parent Phone

Primary Parent Email

Student Email

Family Information

Parent/Guardian 1 – Primary Contact

First Name

Last Name

Home Phone

Cell Phone

Occupation

Work Phone

Address Same as Student

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian 2

First Name

Last Name

Cell Phone

Home Phone

Work Phone

Address Same as Student

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Music Lessons

Does this student or sibling attend Music Together® or Preschool at Preucil?

Yes

Does this student or other immediate family members currently take lessons at Preucil?

Yes

If yes, list name(s) and instrument(s):

How did you hear about the Preucil School of Music?

Instrument Desired:(Required)

Violin

Viola

Cello

Bass

Flute

Piano

Harp

Instrument Desired:(Required)

Violin

Viola

Cello

Piano

Have you taken lessons before?

Yes

If Yes: Prior teacher/program

Reason for transfer:

Dates of study:

Current Literature:

When would you like to begin lessons?

Fall

Spring

Summer

Please check all times you are available for lessons

9AM – 3PM times

Mondays 9am-3pm

Tuesdays 9am-3pm

Wednesdays 9am-3pm

Thursdays 9am-3pm

Fridays 9am-3pm

Saturdays 9am-3pm

Sundays 9am-3pm

3PM – 5PM times

Mondays 3pm-5pm

Tuesdays 3pm-5pm

Wednesdays 3pm-5pm

Thursdays 3pm-5pm

Fridays 3pm-5pm

Saturdays 3pm-5pm

Sundays 3pm-5pm

5PM – 8PM times

Mondays 5pm-8pm

Tuesdays 5pm-8pm

Wednesdays 5pm-8pm

Thursdays 5pm-8pm

Fridays 5pm-8pm

Saturdays 5pm-8pm

Sundays 5pm-8pm

Comments: please include special lesson time circumstances here.

Placement Fee(Required)

Price:

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

This field is for validation purposes and should be left unchanged.

Main Campus
524 N Johnson St
Iowa City, IA 52245
(319) 337-4156

North Campus
2916 Northgate Dr
Iowa City, IA 52245
(319) 248-1248