Whole Child and Adaptive

Lesson Enrollment

Please review our policies and procedures HERE before signing below

Which lesson type are you enrolling for?

Client's First name

Client's Last name

Client's Birthday

Month

Day

Year

Guardian's First and Last Name

Phone

Email

Yes, subscribe me to your newsletter.

What is your communication preference?

Email

Text

Call

What location are you enrolling for?

Hamburg, NY

Williamsville, NY

Bradenton, FL

In Home (must be discussed prior/travel fee applies)

What is your session length preference?

30 minutes

45 minutes

60 minutes

Will you be using any of the following?

OPWDD Self-Directed Budget

FES-UA

What instrument is the client interested in learning/playing?

Guitar

Piano

Voice

Ukulele

Drums

How did you hear about Bloom?

By signing below I acknowledge the above payment and attendance policy

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