Weekly Lessons Registration Form Download printable version here Registration Form Student's Name * Parent(s)/Guardian(s)/or state Adult Student if over 18 * Student's Birth Date * Email * Full Address(es) & Parking Instructions If Applicable * Phone Number * Preferred Method of Communication Email Phone Text Does not matter Other Preferred Method of Communication Name of (and relationship to) the Adult most likely to be home during the lesson (if the student is a minor) * Emergency Contact Name, Number, and Relationship to student * This will be someone OTHER than the person regularly at the home during the lesson Types of pets in the house (if applicable): Medical Information (if applicable ie. Allergies, instructions, etc.): 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) Level (New Students Only) Complete Beginner Beginner with prior musical education Adult Beginner Beginner to Intermediate (1-5 years of instruction) Intermediate Advanced Other Facebook Trial Lesson Offer Level (New Students Only) Lesson time options (returning students only) 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 Lesson time increase (returning students only) 15 Minutes 30 Minutes 45 Minutes Other Lesson time increase (returning students only) Additional Comments: Top 3 choices for a weekly lesson day & time. ie. Mondays @ 5pm 1st Choice * 2nd Choice 3rd Choice Payment Options Please select your payment Option * Credit Card on File: Please use credit card you have on file for me (Returning Students Only) 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 firstname.lastname@example.org for the annual registration fee (30.00) and for the first month of lessons. E- transfers can then be scheduled with your bank for the first of every month thereafter until June of the current school year (or after 30 day notice is given in the case of termination). 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 and a non-process fee (NPF) of $25. Post-Dated Cheques: Please mail [102-1424 Martin St. White Rock, BC V4B3W7] the annual registration fee (30.00) + 10 post-dated cheques for the first of each month Sept-June. See chart in Policies and Procedures for specific monthly amount. Cheques can be made payable to "Music for Life/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 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 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 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 Enter Full Name * Today's Date * If you are human, leave this field blank.