Online Registration Form

Please fill out the following registration form. Time slots are limited, so please register early! We will do our best to accommodate your first preference.

Student's Information
  * Student's Name:
* Your Name:
* Birthday:
(as mm/dd/yyyy)
* Age:
School:
Grade:
Extracurricular Activities:
Previous Music Experience:
  years
* Medical condition(s) or allergies (including food allergies):
Parent's Information
  * Parent(s) Names:
  * Primary Phone Number:
  * Cell Phone Number:
  * Email Address:
  * Address:
  * City:
  * Zip:
Billing Information (if different than above)
Billing Address:
Billing City:
Billing Zip:
Emergency Contact
  * Name:
  * Phone:
Lesson Information
* I am registering for:
Lessons   Summer MusArt Camp   CHIMPS
Rock N Roll Summer Program   Teen Workshops   Adult Summer Program
Adult Workshops   Other
* Preferred Start Date:
(enter as mm/dd/yyyy)
* Instrument Choice:
Piano
Guitar
Brass
Woodwinds
Strings
Voice
Other
Instructor Preference:
With emphasis on
(select one):







Lesson Type
Drop-In Lessons:
30 min @ $40
45 min @ $60
60 min @ $80
4 Private lessons/month :
30 min @ $104
45 min @ $156
60 min @ $200
3 Private & 1 Group/month:
30 min @ $96
45 min @ $132
60 min @ $168
Group Lessons:
$25 each
Group Lesson Type:
None Beginner Intermediate Advanced Other
Private Lesson Time/Day Preference:

MindaMusic Studio is open: Monday-Friday 10-8pm, Saturday 10am-5pm & Sunday 12:30pm-3:30pm

* 1st Preference:
* 2nd Preference:
* 3rd Preference:
Scholarship Request:
I can contribute $ per month.
Please send a copy of last year's 1040 tax return & complete the scholarship application.
How did you hear about MindaMusic?
If other, please specify:
Policies & Payments
 
* I will mail the first session's installment tuition and the $45 non-refundable registration fee per student.
 
* I understand that I am responsible for tuition and music books and agree to all of the Studio Policies.
 
I agree to allow MindaMusic to use photos of and information about my son(s)/daughter(s) on the MindaMusic website and related marketing materials.
Online Signature
 
By providing your full name and the date on which you completed this Online Registration form, you are agreeing that:
- The information you have provided is correct
- That you agree to pay the registration fees and tuition
- That you have read and agree to the Studio Policies
  * Full Name (Including middle initial):
  * Date of Online Registration:
(as mm/dd/yyyy)
* Required
  Enter Security Code