Music Lessons Express Registration Form*
     2008-09 School Year

* Please note that registration is not complete until your registration fee and first month's lesson payment is received
          by the Music Lessons Express office. Visit our home page for instructions on how to submit payment.

* Please Note that all Returning Students will need to complete a registration form.
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We frequently use email to send information and updates.
Please know that Music Lessons Express treats all information submitted to us as confidential.

Please provide the following information:
(for Adult Students you may omit Parent/ Guardian name)

Student's Last name
Student's First name
Grade (or 'Adult')
Primary Contact Parent/Guardian First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip Code
Primary Contact Work Phone	(you may type over the area code if different than 850)
Primary Contact Home Phone
Primary Contact Mobile Phone
Primary Contact E-mail
Verify E-mail

FALL 2008-09     Select one or more instrument/ class below.

Private Percussion            (Offered only at In-Home Lessons at this time)

SuperStar Singing             (offered at Canopy Oaks, Chaires, DeSoto Trail, East Hill, Gilchrist, Hawks Rise, Moore, Sullivan)

Private Voice                    (offered at select locations, call for more information)

Private Flute                     (offered at select locations, call for more information)

   Group Guitar
   Private Guitar

   Group Piano
   Private Piano

   Group Violin
   Private Violin

Please Click on Lesson Location:

Note: Students that attend East Hill should select East Hill (not Sullivan). Also, please provide security
          code( in box near bottom of registration form) so that MLE staff may pick up your child for lessons.

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Is the student a returning student?   Yes No

Is your child in the after-school program? Yes No      If yes, list usual pick up time: PM

If your child is enrolled in other after-school activities on the lesson day, please list activity and time.


Is there a lesson time you prefer? PM.

If the student has any previous musical experience, please briefly describe.

If the student has any medical conditions or other special needs, please describe.

List persons and their relation to the student that are authorized to pick up the student after lessons.

Name

Relation

How did you hear about our program?

    Display at School Event
    Outdoor Sign
    Flyer from After-School Program
    Mailing from Music Lessons Express
    Internet search
    Friend
     Other

Do you have an instrument in your home for practice?
      If yes, please describe the make, model and approximate price paid ("toy instruments" are not
             adequate for developing musicians)
   Make, model, approximate price paid:

    If you currently do not have an instrument at home, you may enroll today, however our policy states that you should
   obtain one within one month.  Without practice at home, developing musicians are easily frustrated and fall behind in lessons.

   Any additional comments you may wish to make:


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Security Code (East Hill Baptist Students only)
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Parent/ Guardian/ Adult Student, please initial boxes below to signify that you agree to the following:
      If either of the first 2 boxes do not apply to you, please leave blank.
____________________________________________________________________________________________________
For students being dropped off for a lesson:
   (including those not registered in the After-School Program on the lesson day)

Parent/ Guardian please initial box to signify that you agree to the following:

        I understand that I must escort my child to the music lesson room and then return to the room when the lesson
               is over to sign my child out.
____________________________________________________________________________________________________

For students enrolled in the first lesson after school:

Parent/ Guardian please initial box to signify that you agree to the following:
         I give my child permission to walk from his/her classroom to the location of the lesson.

[Children in the After school program should check in with after school program prior to coming to music lessons.]

        If you do not agree to this please contact our office (850-219-3653) so that we may make alternate arrangements for
         your child to get to class.
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For all students:
Parent/ Guardian/Adult Student Please type your name in the box to signify that you agree to the following:

     I, (First and Last Name of Parent/ Guardian/ Adult student), have read and agree
to the information and policies of Music Lessons Express. Further, I understand there is an initial commitment of two months' lessons and that a 30-day
notice for withdrawals is required. (Upon request, lessons will be terminated, provided 30 days notice is given. Payment will then be required for all lessons
that would have been received during the 30 day period following the date of withdrawal. Additionally, if a student stops coming to lessons with no notification,
then the student will be charged for the current month plus the following month in order to fulfill the 30 days notification policy.) I will not hold Music Lessons
Express or its instructors liable for any accidental harm or injury caused to a student or student’s property, or damage to school property caused by a student.
I understand that a monthly payment is due by the first of the month and $5 late fee will be added to payments not received by the 5th of the month. I further
understand that a payment reminder will be sent to my email address, but will NOT be mailed to my home address (except to those who do not provide an email
address on this registration form; they will receive invoices by mail). Lastly, I understand that a minimum enrollment requirement must be met in order for lessons
to be provided in my area (see MLE Policies for more detail. If this enrollment is not met, a complete refund will be issued.)
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   Amount Paid   $

   Payment Method     on-line   check/money order

   Date payment made (dd/mm/yy)
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   Remember that your enrollment is not finalized until the Music Lessons Express office has
   received your first monthly payment and registration fee.