Guardian/Adult Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Confirmation of Policies *

I have read The Music Academy policies.

I will allow The Music Academy the use of any photographs, artwork, and recordings for promotional purposes.

I understand that in the event any unpaid balance is placed for collection with any 3rd party collection agency, and/or placed with an attorney to obtain judgement or otherwise satisfy payment of this account, all collection costs, attorney fees, filing fees, interest and court costs will be added to the total amount due.

Student Name 1 *

First Name

Last Name

Teacher *

First Name

Last Name

First Lesson Date *

MM

DD

YYYY

Lesson Length *

30 minutes

45 minutes

60 minutes

Student Name

First Name

Last Name

Teacher

First Name

Last Name

First Lesson Date

MM

DD

YYYY

Lesson Length

30 minutes

45 minutes

60 minutes

Student Name

First Name

Last Name

Teacher

First Name

Last Name

First Lesson Date

MM

DD

YYYY

Lesson Length

30 minutes

45 minutes

60 minutes

I am choosing the following Payment Plan *

Pay in full

Two payments (1st payment due now, 2nd payment due by July 15)

Payment Method *

Use my credit card on file

My card is NOT on file. I will pay on this wesbite.

My card is NOT on file. I will pay in office before my first lesson

I will mail/bring a check