Guardian/Account *

First Name

Last Name

Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Confirmation of Policies *

I understand this one registration form includes up to 36 weeks of instruction, 16 Fall, 16 Spring and 4 Summer.

I understand The Music Academy will contact me with my final total.

I have read The Music Academy policies.

I will allow The Music Academy the use of any photographs, artwork, and recordings for promotional purposes.

I understand that in the event any unpaid balance is placed for collection with any 3rd party collection agency, and/or placed with an attorney to obtain judgement or otherwise satisfy payment of this account, all collection costs, attorney fees, filing fees, interest and court costs will be added to the total amount due.

Student Name 1 *

First Name

Last Name

Teacher *

First Name

Last Name

First Lesson Date *

MM

DD

YYYY

Student Name

First Name

Last Name

Teacher

First Name

Last Name

First Lesson Date

MM

DD

YYYY

Student Name

First Name

Last Name

Teacher

First Name

Last Name

First Lesson Date

MM

DD

YYYY

I am choosing the following Payment Plan *

Pay in full

Two payments

Equal Monthly Payments (thru May)

Payment Method *

Use my credit card on file

My card is NOT on file. I will online here: https://www.musicacademyinrockford.com/pay-tuition

My card is NOT on file. I will pay in office before my first lesson

I will mail/bring a check