Music Program Registration Form

Student's Name

First Name

Last Name

Student's Email Address

Student's Cell Phone

(###)

###

####

Previous piano or guitar instruction?

Yes

If you have had previous instruction, please indicate where.

Academic school year completed.

Parent/Guardian's Name at Student's Address

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Home Phone

(###)

###

####

Parent/Guardian Cell Phone

(###)

###

####

Parent/Guardian Email

All email information is used solely for the purpose of communications between PPAC and the students and their guardians. Your email address will not be sold, or given to any other parties.

Allergies/Medicine/Medical Conditions

Allergies/Medicine/Medical Conditions: Please list any Medical conditions we should be aware of. We will contact you and/or the emergency contact for instruction in the unlikely event of an emergency.

List any allergies/medicine/medical conditions

Release

Release: I, the undersigned parent/guardian of this student, a minor, do hereby release and discharge PPAC Music Program from any and all claims for personal injuries. By entering your name below you agree to be bound by this release.

Parent/Guardian Name

First Name

Last Name

Today's Date

YYYY

Use of images for PAC promotions

I give permission to Presser PAC to use any photographs or media of student in promotional materials, commercials, and or web site.

Yes

Select Class Date and Time

Class Date

YYYY

Class Time

Hour

Minute

Second

Tuition and Non-Refundable Deposit

Nonrefundable $20.00 registration fee, one time only, for the endurance of student’s participation in the Music Program. Tuition due prior to classes beginning, unless otherwise arranged with Instructor.