Your Information *

This agreement is between you (the client) and Jacaranda Music Studios for weekly music instruction.

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

STUDIO LOCATION *

BREA

COSTA MESA (in-home)

Instrument(s)

Piano

Guitar

Drums

Voice

Bass

Ukulele

Banjo

PHOTOGRAPHY & MEDIA *

I grant Jacaranda Music Studios full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.

I do not grant Jacaranda Music Studios image and media rights.

ENROLLMENT AGREEMENT *

I understand and agree to the terms of the agreement above for services of private music lessons given by Jacaranda Music Studios and will abide by the terms of this agreement.

PAYMENT AGREEMENT

Private Lessons *

30-minute weekly lessons: $180 (recommended for 4-9 year olds)

45-minute weekly lessons: $270 (recommended for 10-12 year olds)

60-minute weekly lessons: $360 (recommended for 13 + and students working towards conservatory admission)

Payment Method *

Self Pay

Charter Pay

Authorization *

I agree to purchase tuition as indicated above, based on length of lessons and number of students per the Jacaranda Music Studios price list, as an automatic charge to my credit card, or automatic debit to my checking account on the first of every month.

Billing Period *

I understand that classes and private lessons are billed monthly. If I begin lessons in the middle of a billing period only the remaining lessons within the billing period will be billed to me.

Authorized Card Holder *

I hereby certify that I am the holder of the credit card, or an authorized signer on the bank checking account detailed in the account information on file.

Late Fees and Failed Authorization *

I understand that I will be notified if my credit card or checking account payment fails to authorize for any reason, and that a $20 late fee will apply if I do not provide a valid credit card or payment in full within 5 calendar days of the original rejection date.

Deactivation *

I understand that my lessons will be discontinued if my account becomes more than 10 calendar days late.

Contract Termination *

I understand that this contract may be terminated at the end of any monthly billing period. A completed request must be given in writing at least 14 days prior to my next billing date in order for the request to be effective. Note that refunds cannot be given for mid-month withdrawal from lessons.

Freezing Automatic Payments *

I understand that to temporarily freeze my auto pay, a completed request must be given in writing at least 14 days prior to my next billing date (the first of each month) in order for my request to be effective for that billing date.

Adopt E-Signature *

I agree to adopt this E-Signature

Date *

MM

DD

YYYY