Contact Aliea Wallace

I enjoy hearing your feedback and answering your questions. Please use the form on the right for purchase inquiries as well as to learn more about private lessons. To register for a lesson, please use the text below, copy and paste into the contact box, complete form and click on the send message box.

STUDENT INFORMATION

Name:

Date of Birth:

School:

Allergies:

FAMILY INFORMATION

Name:

Address:

City:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

EMERGENCY CONTACT

Name:

Phone:

Relationship to Student:

LESSON

Class location:

Day:

Time:

Cost:

Registration Fee: $25

Start Date:

POLICIES (Initial)

I have read and understand Aliea's lesson policies:

I give permission for my child to receive medical treatment:

I give permission for my child's photo to be used in publications (optional):