Music Program Registration Form

Student's Name *
Student's Name
Student's Cell Phone *
Student's Cell Phone
Previous piano or guitar instruction? *
Parent/Guardian's Name at Student's Address
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Address *
Parent/Guardian Address
Parent/Guardian Home Phone *
Parent/Guardian Home Phone
Parent/Guardian Cell Phone
Parent/Guardian Cell Phone
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.
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 *
Parent/Guardian Name
Today's Date
Today's Date
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.
Select Class Date and Time
Class Date *
Class Date
Class Time *
Class Time
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.