Quesnel Music Student Enrollment Form

Student’s First Name Student’s Last Name

Address City Postal Code

Home Phone Number Family Email Address Student’s Birth Date (If under 18 years of age)
Month/Day/Year (example 05/22/1996)
1. Parent’s/Guardian’s First name Parent’s/Guardian’s Last name

Home Phone Number Work Phone Number Cell Phone Number

2. Parent’s/Guardian’s First name Parent’s/Guardian’s Last name

Home Phone Number Work Phone Number Cell Phone Number

Comments: This Section to be completed by School administrator

Instrument
Year : 2010-2011
Teacher Lesson Day/Time

Studio # First Lesson

Terms of Agreement
1. Tuition fees are based on ________ lessons.
2. This document is a contractual agreement, which reserves a specific day and time each week (consecutively) for the number of lessons indicated
above.
3. Regarding missed lessons:
a) Student absences will not result in rescheduled lessons, credits or refunds. It is the responsibility of the student/parent to attend the lesson
b) If the teacher cant attend a lesson, a substitute teacher will be provided or the lesson will be rescheduled or, if not possible, the tuition for that lesson
will be refunded at the end of the specified year. If the student fails to show for an agreed rescheduled lesson time, the lesson is forfeited.
4. Regarding termination of lessons:
a) A written notice is required to terminate lessons. Once written notice has been received by Quesnel Music Ltd., payment for a four lesson withdrawal
period is required, whether the lessons are taken or not. The balance of tuition will be refunded after the withdrawal period.
b) There are no refunds to students withdrawing after April 30th of the specified year.
5. Quesnel Music Ltd. Reserves the right to terminate this contract at any time for non-payment of tuition.
6. There is a $25.00 charge for all NSF cheques.
I do hereby declare that I have read and understood this Registration Contract’s Terms of Agreement upon signing this contract.

SIGNATURE: __________________________________ This contract must be signed by a person 19 years of age or older.

Office use only Method of Payment

1 Payment ___Cheque /Debit/cash
Tuition Calculation 40 X $80.00 = $ 800.00
Pre-authorized Credit Card Payment (fill out below)
Month Amount Paid 10 ___Cheques postdated the 1st of each month -
Payments Sept – June

___Pre-authorized Credit Card Payment (fill out below)

Sept 80.00 Credit Card Authorization
Oct 80.00
I hereby authorize Quesnel Music Ltd. to charge my credit card
Nov 80.00 account for tuition.
Dec 80.00 Card____________________________________________
Jan 80.00 Expiry Date: __ __ / __ __ Visa MC (Please Circle)
Feb 80.00
March 80.00 Name on Credit Card (Please Print):
Apr 80.00 ____________________________________________
May 80.00 The undersigned warrants and represents that he/she is authorized to sign for charges to the credit card above.

June 80.00 SIGNATURE: _________________________________