Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Studio Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Name *

First Name

Last Name

Is this student currently enrolled in your studio? *

Yes

No

Duration of student's weekly lesson *

30 min

45 min

60 min

Please check ALL the boxes below *

By checking this box, as a Massachusetts Music Teachers Association in good standing, I agree that, should the aforementioned student be accepted into the MMTA Music Connect Program, I will accept this student, (student’s name) into my studio and offer him/her all the regular benefits of my studio for the academic year. I understand that I will be reimbursed at the rate of $60.00 per teaching hour, at eight-week intervals, after filing the Teacher Evaluation/Verification Form with the Music Connect Program Chair, for the approved number of hours.

I have read and I accept and agree to the terms of the MMTA Music Connect Program stated separately in the “Description for MMTA Teachers” and in the “Description for Student’s Parent or Guardian.”

Date *

Today's date

MM

DD

YYYY