This is a Year Round Class!

CLICK TO READ – Music On Wheels Academy Policies

One application PER student

Offering 1 hour Piano Classes or 30-Minute Private Instrument Lessons (Piano,Vocal, Drums) – Hollydale UMC location ONLY

Phone

Student First Name

Student Last Name

E-mail - 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.

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.

Cell Phone

Gender *

Address *

City *

State *

Zip

Student Age *

Hollydale UMC Piano Lessons - This is a year round class - $100 Yearly Registration fee is required. *

Yearly Registration fee is required at registration with 1st payment

Name of School Student Attending - Class day and time will be e-mailed. *

Print Parent/Guardian Consent to Child's Participation *

I consent to my child's participation in Music On Wheels Academy of Music & Arts.

Student First & Last Name *

Payment Option - Full Initial payment is due BEFORE the start of class.

Full Initial payment is due BEFORE the start of class.

Debit/Credit Card Number - Account will be debited upon receipt of application.

Account will be debited within 24 hours of receipt of application.

Exp Date

3-Digit Code on Back

Billing Zip Code

Quarterly Tuition Payment - 1 hr Piano Class - READ ONLY

Quarterly Tuition per student: Four tuition payments are required during the year reflecting 3 months. Payments are debited quarterly. A Registration fee of $100 is required with the first tuition payment of $65. There is a $35 late fee for all payments received after the 7th of the month, when a payment is due. Students/Parents are required to purchase music books and/or an instrument. Books can be purchased online at www.musiconwheelsga.com/store. There are no refunds. ALL fees paid are non-refundable.

Quarterly Tuition Payment - 30 min Private Piano - READ ONLY

Quarterly Tuition per student: Four tuition payments are required during the year reflecting 3 months. Payments are debited quarterly. A Registration fee of $80 is required with the first tuition payment. There is a $35 late fee for all payments received after the 7th of the month, when a payment is due. Students/Parents are required to purchase music books and/or an instrument. Books can be purchased online at www.musiconwheelsga.com/store. There are no refunds. ALL fees paid are non-refundable.

Automatic Monthly Debit - 1 hr Piano Class - READ ONLY

Automatic Debit per student: Your account will be debited on the 1st of each month, after the 1st initial payment is paid. The first initial payment of $165 will be debited upon receipt of a completed application. The first initial payment includes tuition plus a $100 annual registration and book fee. There is a $35 late fee for all payments received after the 7th of the month. To cancel, a 30-day written notice must be submitted to avoid the next account debit. There is a $35 cancellation fee for cancellations without a 30-day notice. There are no refunds. ALL fees paid are non-refundable.

Automatic Monthly Debit - 30 min Private Piano - READ ONLY

Automatic Debit per student: Your account will be debited on the 1st of each month. The first payment includes tuition plus an additional $80 for annual registration. There is a $35 late fee for all payments received after the 7th of the month. To cancel, a 30-day written notice must be submitted to avoid the next account debit. There is a $35 cancellation fee for cancellations without a 30-day notice. Parents/Students are required to purchase music books and/or instrument rental fees online at www.musiconwheelsga.com/store. There are no refunds. ALL fees paid are non-refundable.

Parent/Guardian Signature to Consent to Debit

I authorize Music On Wheels, LLC to debit my account as indicated above for tuition. By typing in my name, I acknowledge that I am signing to consent to the above information. I also understand that there is a $35 fee if my payment is late. (Paid after the 7th)

Student First & Last Name *

Waiver & Release of Liability - Parent/Guardian Signature *

This activity is not a Cobb County school district program. As a parent/legal guardian, I hold Hollydale United Methodist Church and all of its affiliate members ad faculty harmless against any and all liability claims, judgments or damages arising as a result of participating in this program. This program has inherent risks for student injury and as the parent/legal guardian, I acknowledge and assume the responsibility of potential injury to myself/my child. 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, LLC and /or their directors, officers, employees, volunteers, representatives, and agents, the activity or eventholders, schools, 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, LLC. 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. The 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 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. 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. 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, 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 yearly registration fee is due August of each year. I understand there are no refunds. if i decide to cancel services, i understand that i must submit a written 30-day notice in advance to stop debit payments or i will be charged a $35 cancellation fee. I have also received the 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 Student Enrollment Manuel, and this entire form regarding payment, liability waiver, and release of Photography and video.

Parent/Guardian Signature - Read/Understand Music On Wheels' Policies

I have read the above and consent.

https://musiconwheelsga.com/our-policies/ *

Parent/Guardian Signature - Acknowledge Music On Wheels, LLC Policies & Procedures

By typing my name, I acknowledge, understand, and consent to Music On Wheels, LLC policies and procedures.