LESSON AGREEMENT FORM |

LESSON AGREEMENT

PLEASE FILL OUT THE FOLLOWING INFORMATION IN ORDER TO COMPLETE REGISTRATION.

I. STUDENT INFORMATION

Student Name *

First

Last

Student Birth Date *

Race/Ethnicity (for reporting purposes) *

Student #2 Name

First

Last

Student #2 Birth Date

Race/Ethnicity (for reporting purposes)

Parent/Guardian Name

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Home Phone *

Home/Cell Phone can be the same.

Cell Phone *

Home/Cell Phone can be the same.

II. REGISTRATION INFORMATION

Learning Format *

Instructor Name *

Instructor Name

Day/Time of Weekly Learning *

III. CREDIT/DEBIT CARD INFORMATION

All payments are made through automatic withdrawal. If you wish to provide this information in person or over the phone, please reach out to Katherine and schedule a time to do so. Lessons are not authorized until card information is on file.

Option: You can add your own credit/debit card information on the student portal by logging in, going to "profile settings" under your name, and then clicking on "add card." Please let us know below your status: *

Card Type *

Visa
MasterCard
Discover
American Express

Credit/Debit Card Number *

Expiration Date *

CVV/CSC Number *

3-4 digit number on the back of your card

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

I AUTHORIZE STEEPLE STREET MUSIC ACADEMY TO AUTOMATICALLY CHARGE MY CREDIT/DEBIT CARD ON FILE EACH MONTH FOR LESSONS, ACCORDING TO SCHOOL POLICIES. *

Please provide your electronic signature in order to agree to the terms.

IV. SCHOOL POLICIES & GUIDELINES

Please read the STUDENT HANDBOOK, provided via email from info@steeplestreetmusic.com and available on the student portal under "Online Resources."

I ACKNOWLEDGE THAT I HAVE READ AND AGREE TO ADHERE TO THE POLICIES AND GUIDELINES AS OUTLINED IN THE STEEPLE STREET MUSIC ACADEMY STUDENT HANDBOOK. *

Please provide your electronic signature in order to agree to the terms.

V. LESSON LIABILITIES & RELEASES (also available to read on the student portal)

1. CHILD SAFETY. To ensure your child’s safety, please be sure to pick him/her up promptly after class/lesson time. Steeple Street Music Academy’s instructors and staff do not supervise children waiting in hallways before and/or after classes/lessons. Children are under supervision during their instruction time only. Neither instructors nor staff are responsible for supervising children outside of teaching time. 2. MEDICAL EMERGENCIES. Unless written notice is given to the studio, permission is granted to Steeple Street Music Academy and its operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. Parent/Guardian must also submit written notice for any physical/mental problems, restrictions or conditions. 3. INJURIES. Parents, legal guardians of minor students and adult students waive the right to any legal action for any injury sustained on school property resulting from normal lesson activity or any other activity conducted by the students before, during or after lesson time. 4. RELEASE OF LIABILITY. Parents, legal guardians of minor students and adult students fully waive and relinquish any and all claims against Steeple Street Music Academy and its owners, instructors, agents and employees from injuries or damages as a result of participating in any activities or classes in any way associated with Steeple Street Music Academy. Parents, legal guardians of minor students and adult students further agree to indemnify and hold harmless Steeple Street Music Academy from any and all claims resulting in injuries, damages arising out of, connected with or in any way associated with the activities of any of the programs. 4. PHOTO/VIDEO RELEASE. Steeple Street Music Academy is hereby granted permission to take photographs and or video of the students to use in newspaper, TV press release, brochures, websites, posters, and other promotional materials the school creates. Please be aware that these photos or recordings are for promotional purposes and may be used in future print or electronic publications and media communications. Permission is also hereby granted for the school to copyright such photographs and video footage in its name. By participating in Steeple Street Music Academy’s programs, you consent to the video or audio recording or taking of photographs for these purposes. Prior approval from the student/parent will be asked if personal information is to be attached to the photos or recordings. 6. CHANGES & UPDATES. We reserve the right to update or modify these policies at any time and without prior notice unless a material change is made; in which case we will notify you through the email you have on file. Your use of our services following any such change constitutes your agreement to follow and be bound by the policies as changed.

I ACKNOWLEDGE THAT I HAVE READ AND AGREE TO ADHERE TO THE LESSON LIABILITIES & RELEASES AT STEEPLE STREET MUSIC ACADEMY.

Please provide your electronic signature in order to agree to the terms.