Music On Wheels Academy of Performing Arts Application Application Type(Required) Application TypeHome/In-Office LessonsChurch / Community Center LessonsPublic / Private School Class PianoVirtual Lessons Category Program Selection Course Fee Monthly Registration Fee Only one student per applicationNote: It is the responsibility of the Parent/Student/Guardian to Check E-mails and Website Periodically for Important Information/Updates from Music On Wheels Academy.Private lessons are 30-minutes. Parents may purchase additional time.Note: An additional $80.00 for Yearly Registration is required at registration. Private lessons are 30-minutes. Parents may purchase additional time.Note: An additional $80.00 for Yearly Registration is required at registration. This is a YEAR-ROUND class.Note: An additional yearly fee of $155.00 Registration and Costume Rental fee is required at registration. There may be additional rehearsals for performances at no extra charge. Please note that it is the discretion of the dance teacher to determine which class will fit the student. Offering 1 hour Piano Classes or 30-Minute Private Instrument Lessons (Piano,Vocal, Drums) – Hollydale UMC location ONLYCLICK TO READ – Music On Wheels Academy PoliciesOffering 1 hour Piano Classes or 30-Minute Private Instrument Lessons (Piano,Vocal, Drums) – Cherokee Charter ONLY CLICK TO READ – Music On Wheels Academy PoliciesOffering 1 hour Piano Classes or 30-Minute Private Instrument Lessons (Piano,Vocal, Drums) – Cobb County Schools ONLY CLICK TO READ – Music On Wheels Academy PoliciesOffering 1 hour Piano Classes or 30-Minute Private Instrument Lessons (Piano,Vocal, Drums) – Open Bible Tabernacle location ONLYCLICK TO READ – Music On Wheels Academy PoliciesOffering 1 hour Piano Classes or 30-Minute Private Instrument Lessons (Piano,Vocal, Drums) – Cherokee County Schools ONLY Note: Students are REQUIRED to be enrolled in ASP. There is a fee. Please see your child’s ASP Director at your child’s school.CLICK TO READ – Music On Wheels Academy PoliciesPiano Lessons – This class runs September – May ($100 Yearly Registration fee is required). Please be aware of our financial policy before registering for our program. *Piano Lessons – This class runs September – May ($100 Yearly Registration fee is required). Please be aware of our financial policy before registering for our program. *Piano Lessons – This class runs September – May ($100 Yearly Registration fee is required). Please be aware of our financial policy before registering for our program. *Piano Lessons – This class runs September – May ($100 Yearly Registration fee is required). Please be aware of our financial policy before registering for our program. *Piano Lessons – This class runs September – May ($100 Yearly Registration fee is required). Please be aware of our financial policy before registering for our program. *Piano Lessons – This class runs September – May ($100 Yearly Registration fee is required). Please be aware of our financial policy before registering for our program. *Student InformationName(Required) First Last Email(Required) Phone / Mobile(Required)Age(Required)Please enter a number from 1 to 100.Gender(Required)Choose GenderMaleFemaleAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Name of School Student Attends – Class day and time will be emailed(Required) Parent InformationRequired only if student is a minorName(Required) First Last PhoneEmail Interval / FeesPayment Interval(Required)Automatic Monthly DebitAutomatic Quarterly DebitCourse Fee Price: $0.00 Registration Fee Price: $0.00 Subtotal $0.00 Total Payment MethodCredit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Automatic Monthly DebitAutomatic Quarterly DebitAutomatic Monthly DebitAutomatic Quarterly DebitAutomatic Monthly Debit – 1 hr Piano ClassAutomatic Quarterly Debit – 1 hr Piano ClassAutomatic Monthly Debit – 30 min Private Instrument ClassAutomatic Quarterly Debit – 30 min Private Instrument ClassAutomatic Monthly Debit – 1 hr Piano ClassAutomatic Quarterly Debit – 1 hr Piano ClassAutomatic Monthly Debit – 30 min Private PianoAutomatic Quarterly Debit – 30 Min Private PianoAutomatic Monthly Debit – 1 hr Piano ClassAutomatic Quarterly Debit – 1 hr Piano ClassAutomatic Monthly Debit – 30 min Private PianoAutomatic Quarterly Debit – 30 Min Private PianoAutomatic Monthly Debit – 1 hr Piano ClassAutomatic Quarterly Debit – 1 hr Piano ClassAutomatic Monthly Debit – 30 min Private PianoAutomatic Quarterly Debit – 30 Min Private PianoConsent / Waiver & SignatureConsent(Required) I agree to the participation policy.Participation Policy * I consent to participation in Music On Wheels Academy of Music & Arts. Consent(Required) Dance Class Policy.In understand that the class is scheduled year-round and will last for 45 minutes each session.Consent(Required) Dance Class Policy.In understand that the class is scheduled year-round and will last for 45 minutes each session.Consent(Required) Hollydale UMC Policy.I understand that the class is scheduled year-round and a yearly registration of $100 is requiredConsent(Required) I agree to the payment policy.Payment and Late Fees Policy * By signing my name below, I authorize Music On Wheels, LLC to debit the above account for tuition fees. I acknowledge and consent to the above information. Please note that a late payment fee of $35 will be charged if payment is made after the 7th of the month. Waiver(Required) I agree to the Waiver & release of Liability policy. Waiver & Release of Liability * I waive, release and discharge from any and all liability, including but not limited to liability arising from the negligence or fault of the entities or persons released: Music On Wheels, and /or their directors, officers, employees, volunteers, representatives, and agents, the activity or eventholders, sponsors, or volunteers. I indemnify, hold harmless, and promise not to sue the entities mentioned in this paragraph from all liabilities and claims resulting from participation in classes, lessons, events, or activities due to negligence, errors, omissions, acts, or failures to act of any party or entity conducting services, activities, or events on behalf of Music On Wheels. I acknowledge that this activity or event may involve a test of a person’s physical and mental limits and may carry with it the potential for serious injury, property loss, or death. Risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, health condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to participants, but are also present for staff. I understand that risk of injury is inherent in any physical activity, and I, on behalf of myself/my child, knowingly and voluntarily accept that risk that may include but is not limited to heart, back, medical, allergy, muscular, pregnancy, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc. I further certify that the aforementioned student is in proper physical condition to participate in the exercise/dance program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in the Music On Wheels program. I hereby consent my child to receive medical treatment, which may be deemed advisable in the event of injury, accident, and/or illness during this class, activity or event. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make Music On Wheels, LLC responsible for payment of medical expenses. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I also understand that at this event or related activities, I/my child may be photographed or videotaped in activities described within Music on Wheels’ program. I agree to allow photos, video, Internet advertisement, and/or film to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, for marketing, informational, or educational purposes. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY AGREE AND UNDERSTAND ITS CONTENT. I understand this is a year round program and a yearly registration fee is due August of each year(after 1st year). I understand there are no refunds. lessons are recurrent. If I decide to cancel services, I understand that I must submit a written 30 day notice in advance to stop debit payments, or be charged a $35 cancellation fee. I have also received the Parent/Student Enrollment Handbook and I understand that I am responsible and accountable to the information enclosed. I give my child permission to participate in the Music On Wheels Program under the guidelines set forth in the Parent/Student Enrollment Manuel, and this entire form regarding payment, liability waiver, and release of Photography and video.Signature(Required) By typing you full name, you are signing this application and it is a legally binding document.PhoneThis field is for validation purposes and should be left unchanged. Δ
