Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Confidential Communication Agreement: Can we call/leave a message on your phone? *

Yes

No

Legal Guardian (indicate SELF, if self) *

First Name

Last Name

Legal Guardian Phone (if needed)

(###)

###

####

Preferred Studio location *

Downtown Waukesha

West Milwaukee

Both

Are you a military veteran?

Yes

No

Are you 65 or older and living with memory loss?

Yes

No