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Private Music Lesson Registration Form: Emergency Contact

This form is used to register a student for private music lessons at Artistic Motion. It collects information such as the student's name, age, address, emergency contact, and preferred lesson time and instructor. Payment options include paying per semester in full or monthly. The student's parent or guardian must sign a release of liability agreeing to absolve Artistic Motion of responsibility for any damages incurred during music lessons.

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Adam
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103 views1 page

Private Music Lesson Registration Form: Emergency Contact

This form is used to register a student for private music lessons at Artistic Motion. It collects information such as the student's name, age, address, emergency contact, and preferred lesson time and instructor. Payment options include paying per semester in full or monthly. The student's parent or guardian must sign a release of liability agreeing to absolve Artistic Motion of responsibility for any damages incurred during music lessons.

Uploaded by

Adam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Private Music Lesson Registration Form

Student Name: Age: Sex: ____

Address: City: State: NC Zip: _______

Parent A: Phone (H) (W) ______________

Parent B: Phone (H) (W) ______________________

Cell Phones: (A) (B) ____________________________

Email: _______________________________________ Check here to allow the student’s picture to be


used in Artistic Motion’s promotional materials.
Emergency Contact:

Name: Phone:

Student’s Doctor: Office Phone:

Private Voice / Private Piano (circle one) Preferred Day/Time: Lesson Length: _________

Private Voice / Private Piano (circle one) Preferred Day/Time: Lesson Length: _________

Preferred Instructor (if applicable): _________________________________________________________________

How long has your child been with Artistic Motion? _____________________

Payment Options: 1 Semester in Full (upon enrollment, based on weekly lesson schedule)
Per Month

Lesson Fee $_____________ x _____________ lessons per semester


Please Mail To:
Lesson Fee $_____________ x _____________ lessons per semester
Artistic Motion
Administrative fee: $ 35.00 (due with registration form each semester) 312 N. Eugene St.
Total Amount Due $____________ Greensboro, NC 27401
Total Lesson Fees $

Amount Paid $ ________________ Amount Due $ _______________

***Please make check payable to Artistic Motion***

Release of Liability:
I hereby release Artistic Motion, its members, agents and volunteers of all liability. By signing this release, I understand that I am absolving and
releasing others from liability from their own negligent acts, even if I am not at fault in any way. In consideration of my/my child’s participation in
classes or other activities at or associated with Artistic Motion, I agree to assume full responsibility for them, their heirs, executors, and
administrators, waive and release and forever discharge any and all rights and claims for damages which they may have or which occur to them, for
all damages which may be sustained and suffered by them in connection with their association with or entry into center activities or which may arise
out of their participation in these activities. I expressly assume all of the risks inherent in these activities.

Signed: ______________________________________________________________ Date: ______________

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