Private Lesson's Fall Registration

Student's First Name*

Student's Last Name*

Address*

Address line 2

City*

State*

Zip*

Please check this Box if the Student has any special needs. We will email you to discuss further

Parent/Guardian First Name

Parent/Guardian Last Name

Parent Guardian #2 First Name

Parent Guardian #2 Last Name

Phone*

Email*

Emergency Contact First and Last Name*

Emergency Contact's Phone*

Emergency Contact's Email*

Buffalo Academy of Irish Music

Buffalo, NY, USA

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