Student's First Name*		Middle Name
Last Name*		Nickname
Gender*	Male    Female	Date of Birth*
Address*
City*
State*	AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming	Zip*
Home Phone*
Work Phone*	Phone number is for: Parent Guardian Student
Cell Phone	Phone number is for: Parent Guardian Student
Email
If student is under 18 years old
School
Grade
Parent/Guardian name(s)*
Parent/Guardian Email
Private Music Instruction (Your instructor will call you to arrange your lesson time.)
Instrument*	Piano Voice Guitar Percussion/Drum Team
Choose preferred day of week and duration of lesson.*
Monday Tuesday Wednesday Thursday Friday Saturday	30 Minutes 45 Minutes 60 Minutes
Preferred Instructor

* Denotes a required field.

UA Fort Smith requires that a parental consent form be completed and returned to Dr. Walker or your instructor.

The Academy of the Arts is a division of the Center for Lifelong Learning. UA Fort Smith reserves the right to use photos and videos of all Academy students in promoting the arts.