Music On Wheels Academy of Music & Arts » Virtual Zoom Lessons Application

One Application PER Student

Private lessons are 30-minutes. Parents may purchase additional time.

Name

Student First 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.

Student Last Name *

Cell Phone

Gender *

Address *

City *

State *

Zip Code

Student Age *

Music Selection & Pricing *

An additional $80.00 for Yearly Registration is required at registration.

Print Parent/Guardian

I consent to participation in Music On Wheels Academy of Music & Arts.

Student First & Last Name *

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

Full Initial payment is due BEFORE the start of lessons.

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 - READ ONLY

Quarterly Tuition per student: Four tuition payments are required during the year reflecting 3 months. Payments are debited quarterly on the 1st day of the month it is due. A Registration fee of $80 is required with the first quarterly 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 - 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

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 *

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.

Parent/Guardian Signature

I have read the above and consent.

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

Parent/Guardian Signature

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