Registration - DFW Music Academy

Student Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Student's Phone

Student's Email

Student's Birthday *

Sex *

Male
Female

Student's School *

Student's Grade *

Medical Information that DFW Music Academy staff and instructors need to know: *

Parent Information:

Parent Name *

CIRCLE Policies Phone

Parent's Email *

Phone *

Parent Employer:

Work Phone *

Additional Parent Name

Parent's Email

Phone

Parent Employer:

Work Phone

Emergency Contact Information:

Emergency Contact Name *

Phone *

Above address same as billing? *

Yes
No

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Where did you hear about us? *

Internet Search
Friend
Social Media
Other

Referral Friend *

If Other *

Instruments

I am registering for *

Saturday Band Class 9:45 am
Saturday Band Class 11:45 am
Saturday Vocal Class 10:45 am
Private Lessons

Private Lessons Location

Grapevine Studio Lessons
Keller Studio Lessons
At Home Lessons

Instrument choice for private lessons *

Membership Agreement & Policies

Each student must sign off to have a card or bank draft on file and agree to be drafted each month on the 1st.
All lesson fees will be drafted on the 1st of each month.
During months with holidays, the lessons must be made up if the student chooses to cancel. (Lessons will not be prorated)
Lessons must be rescheduled, or the student forfeits the lesson fee.
The make-up lesson must occur within the month of the missed lesson.
If the instructor is unavailable for the makeup lesson, the lesson fee will not be refunded.
If the instructor needs to cancel, the lesson will be made up.
If a makeup lesson can not be rescheduled, you can attend the monthly "Music Theory" class instead.
No-shows will not be refunded/rescheduled.
If a student is more than 15 minutes late, they will be considered a no-show, and teachers will not be required to stay for the remainder of the lesson time.
If the student wants to cancel lessons, you must cancel before the beginning of a new month, or you will be responsible for the entire month’s fees. No remaining lessons will be refunded.
There is no proration for missed classes or holidays for the band class.

In-Studio Lesson Prices: (monthly)

30 min lesson $158
45 min lesson $198
60 min lesson $248

In-Home Lesson Prices: (monthly)

30 min lesson $198
45 min lesson $248
60 min lesson $288

Group Class Prices:

$98 per month (no proration for missed classes or holidays)
$75 per month for each additional child
$75 per month for each additional class

Annual Registration Fee:

(Group and Private Lessons)

(Upon Registration and each August)

New Students: $40
$20 for each additional child

Returning Students: $30
$15 for each additional child

Do you agree to the above Policy? *

I agree

Signature *

Clear Signature

I agree to the terms and conditions

Autopay

Choose which form of payment you want to authorize: (Preferred method of payment is EFT-Bank Draft) CIRCLE WHICH OPTION YOU PREFER BELOW *

Debit/Credit Card Payment(MASTER CARD & VISA ONLY)
EFT Bank Draft

Electronic Funds Transfer Authorization Form (EFT) – Bank Draft – (Preferred Discounted Method)-

As a duly authorized check signer on the financial institution listed below, I authorize DFW Music Academy to perform scheduled or periodic electronic funds transfer debits and/or credits from my account identified below for payments due or when applicable, apply electronic funds credits to the same. This applies to check by phone payments as well as any other electronic payments. I understand the dollar amount can vary depending on the services performed. Monthly tuition payments will be transferred on the 1^st of every month. Furthermore, if any such electronic debit(s) should be returned by my financial institution for any reason, including non-sufficient funds (NSF), I authorize DFWMA to collect a returned item fee of $30.00 per item by electronic debit from my account identified below. For accounting purposes, all electronic debits will be reflected in the monthly bank statement that corresponds with the account identified below.

I understand and authorize all the above as evidenced by my signature below. *

Clear Signature

Today's Date *

Financial Institution Account “Identifying Information”:

Enter financial institution account information into the fields provided below.

Financial Institution: *

9 Digit Transit/ABA # *

Account # *

Debit/Credit Card Authorization – Debit/Credit Card Payments –

*All Debit Cards will process as a credit card*

I authorize DFW Music Academy to perform scheduled or periodic electronic funds transfer debits and/or credits from my account identified below for payments due or, when applicable, apply electronic funds transfer credits to the same. There is a small convenience fee for using CC/Debit option. I understand the dollar amount can vary depending on services performed. Monthly lesson payments will be transferred on the 1^st of every month. **I agree that if my balance is not paid in full by the end of the year, that DFWMA has the authority to put my remaining balance due on the credit card below.

Please Choose *

Visa
Mastercard

Card # *

Exp: *

CVC: *

Zip: *

Today's Date *

Signature *

Clear Signature