Independence School of Music
Registration Form - Sept 1 2007 thru Aug 31 2008
(print out this form)

Student Name _________________________________________   (M/F) ( Youth or Adult )

Address _____________________________________   City ______________   Zip _______   

Student Phone ______________________   School  _______________________   Grade _____ (youth)

Student Email _________________________________Student Birth Day ____ / ____ / ____ (youth)

Prior Music Education ________________________________________________________

How did you hear of us  _______________________________________________________

Medical Conditions __________________________________________________________

Non-music interests __________________________________________________________

Lesson Information:   Instrument ________________________

Day of Week    _____________   Time of Day ____________  Teacher ________________

Tuition: $80 per month         _____________________________________________________________________  

Lesson Policy: Student tuition is due on or before the first lesson date of each month.  The School guarantees a minimum of four (4) lessons per month.  There are no refunds for missed lessons, unless the teacher cancels the lesson and is unable to offer a minimum of 4 lessons during that month.  For student cancelled lessons, Independence School of Music will schedule up to one make-up lesson per month subject to teacher availability, provided that 24 hour notice has been given prior to cancellation of lesson.  Monthly Tuition rates for each teacher are established for the school year beginning September 1 of each year. Students who attend lessons throughout the summer months shall be retained beginning September 1 at the prior year's established tuition rates. 

Payment Policy: We accept cash, check or credit card, or automatic checking account debit.  There is a $3 surcharge for credit card payments due to credit card processing fees.  Our preferred method of payment is automatic debit from a checking account.

Payment Authorization
The undersigned authorizes automatic payment in the amount of _______ from my (checking account / credit card) each month on or after the 1st of the month. 

Name on Account __________________________________  Address ________________________________________

Credit Card:  Type (MC/VISA/AM EXP/DISC) Account # ______________________________________  Expiration ________

or Checking: Bank ______________________ Routing ___________________  Account _________________________

Signature _______________________________________________________  Date _____________

Parent Information (for school age students) Indicate N/A if not applicable

Father's Name _______________________   Mother's Name _______________________

Father's Phone _______________________  Mother's Phone _______________________

Email ________________________________  Email __________________________________

Emergency Contact & Phone ____________________________________________________