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Student Registration Form

Student #1

Are you a returning student?
If Yes, who is your teacher?
Student Name:*
Registering for what program?*

PLEASE NOTE: If registering for School Lessons, your school must already be set up for lessons.

Lesson length:*
Please list any previous musical education if any:
Is the student an Adult?*
Birthdate (if under 18):

Student #2

(2) Are you a returning student?
(2) If Yes, who is your teacher?
(2) Student Name:
(2) Registering for what program?

PLEASE NOTE: If registering for School Lessons, your school must already be set up for lessons.

(2) Lesson length:
(2) Please list any previous musical education if any:
(2) Is the student an Adult?
(2) Birthdate (if under 18):

Student #3

(3) Are you a returning student?
(3) If Yes, who is your teacher?
(3) Student Name:
(3) Registering for what program?

PLEASE NOTE: If registering for School Lessons, your school must already be set up for lessons.

(3) Lesson length:
(3) Please list any previous musical education if any:
(3) Is the student an Adult?
(3) Birthdate (if under 18):

Contact Information

Parent or Guardian Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
E-mail:
How did you hear about us?
Please list all days and times that are possible for lessons:
School Name if registering for School Lessons, and any other information:
How would you like to pay?

Credit Card Information

Card Type:
If other please specify:
Name on Credit Card:
Credit Card Number:
Expiry Date:

I understand that my credit card information will be used to securely provide payments to Academy of Music on a recurring monthly basis until the end of June within the current school year.

I have read the Tuition and Policies

Yes*

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