‎ – Music from the Heart

Registration

Student Name *

First

Last

Select Class *

Select (Private Lessons Only)

Email *

Phone Number *

Street Address *

Apartment, Suite, etc.

City *

Postal Code *

Contact (Parent/Guardian) Name(s) *

Emergency Contact Name *

Emergency Contact Phone *

Medicare Number *

Does the student have any medical conditions which could affect his/her participation in class? *

Does the student have any food allergies? *

Acknowledgement *

I agree to the fees and policies of Music from the Heart.

This acknowledges that I have enrolled my child/myself for lessons at Music from the Heart, and I understand that any activity which includes motion may cause accidental injury. I accept responsibility for any injury which may arise from such activity. If I am unable to be reached in the event of injury, I grant permission to Music from the Heart to give medical treatment, if necessary. I understand that I am responsible for paying for all lessons whether I/my child attends the lesson or not. Furthermore, I understand when payments are due, and will make payments on time. Also, should I fail to meet the deadline for registration, my/my child's space at Music from the Heart will be available to other students. Lessons will not be given until payment is received.

I have fully read, understood, and agree to the fees and policies of Music from the Heart.