The Music Place
ASSESSMENT REQUEST FORM
Use this form to request a free assessment for students 3 years and up or students of any age who have special needs. Assessments are offered in San Jose on Tuesdays, Fridays & Saturdays with time options noted below.
Student & Family Information
Scheduling Your Assessment
Please give information for the student needing options
Student First & Last Name
Date of Birth
Does this child need special attention or have special needs?
Please explain your child's needs or diagnosis:
Has this family been enrolled at The Music Place previously?
NO, our family is new to the Music Place
YES, our family has been enrolled previously
Voucher or Coupon Code?
Parent Contact Information
Mom First Name
Mom Last Name
Dad First Name
Dad Last Name
Best Phone Number
Whose phone # is this?
Address or Nearest Cross Streets
Reason for Assessment (Check All That Apply)
Child under 7 interested in instrumental lessons
Need First steps placement advice
One of my children has special needs
Re-assessment check in
Need 2nd instrument placement advice
Please note your goal in this assessment:
If your goal for the assessment is something other than what is listed, please make note of it here.
Do Not Fill This Out