Pre-Registration Form (Returning Students Only) Student's Name * Parent(s)/Guardian(s)/or state Adult Student if over 18 * Student's Birth Date * Month/Day Email * Full Address(es) & Parking Instructions If Applicable * Phone Number * Preferred Method of Communication * Email Phone Text Does not matter Other Facebook Preferred Method of Communication Preferred Platform for Virtual Lessons * Zoom Google Duo Facetime Microsoft Teams Facebook Messenger Skype Does not matter Other Preferred Platform for Virtual Lessons One adult is required to be home during the lesson. Please list the name(s)ame and relationship to student of the person(s) most likely to be home during the lessons * Type "Self" if you are an adult student over 18 years of age Emergency Contact Name, Number & Relationship to student (other than the person who is most likely to be at home during the lesson) * Medical Information (if applicable ie. Allergies, instructions, etc.): Types of pets in the house (in-home lessons only): Instrument(s) * Piano Violin Guitar Voice Viola Ukulele Theory Drums Bass Guitar Stand Up Bass Rock Band Summer Camp Violin Intensive Summer Camp Violin & Piano Violin & Guitar Voice & Piano Voice & Guitar Violin, Piano, Guitar Guitar & Bass Drums & Guitar Guitar & Piano Voice, Guitar & Piano Other Instrument(s) Lesson time increase (leave blank if you do not wish to increase your lesson time) 15 Minutes 30 Minutes 45 Minutes Other Lesson time increase (leave blank if you do not wish to increase your lesson time) Lesson time options If it is still available, I would like to keep my lesson time and day the same I am not sure yet what time will work for me in the Fall but would still like to register during this time I would rather not keep my current lesson time in the Fall but if there isn’t a better alternative I can keep it I would like to change my lesson time and/or day. Please see below for my top 3 choices Making a request for a new lesson time or day? - please fill in your top 3 choices. ie. Mondays 5pm 1st Choice 2nd Choice 3rd Choice Additional Comments: Payment Options Please select your payment Option * Credit Card on File: Please use credit card you have on file for me to charge me the Early Bird Rate 23.00 (before May 27, 2022)/Regular Rate 30.00 for form submitted after May 17, 2021. This card can be used for the following monthly payments starting on September 1st. New Credit Card: After submitting this form, someone will contact you by phone to gather your Credit Card Details. You may also call our secure line 604-338-2742 to speak with someone or leave a message. E-transfer: Please send an initial e-transfer to music4life.tina@gmail.com for the Early Bird rate of 23.00 (before May 27, 2022)/Regular Rate 30.00. E- transfers should then be made on the first of every month thereafter until June of the current school year (or after 30 day notice is given in the case of withdrawal). Note: A Backup Credit Card is required on file to qualify for this option. Please call 604-338-2742 to provide details. In the event that the payment is not received by the first of each month, your credit card will be charged for the lesson amount in addition to a non-process fee (NPF) of $25. Post-Dated Cheques: Please mail [102-1424 Martin St., White Rock, BC V4B3W7] the annual registration fee Early Bird Rate 23.00 (before May 27, 2022)/Regular Rate 30.00 + 10 post-dated cheques for the first of each month Sept-June. See chart in www.music4life.ca/rates for specific monthly amount. Cheques can be made payable to "Music for Life School of Music/Tina Tate." Note: A Backup Credit Card is required on file to qualify for this option. Please call 604-338-2742 to provide details. There is a $25 NSF fee and lessons can be withheld until the matter is resolved. Confirmation By Checking the Box Below You certify that the information provided on this application is accurate. I understand that withholding of information or giving false information may result in discontinuation of services * Yes the information provided is accurate and correct I have read, understand, and will adhere to the Policies and Procedures. I am aware that policies may change and that I will be notified by email * Yes Enter Full Name * Today's Date * Email If you are human, leave this field blank.
