Fiddlehead PAYMENT Form

STUDENT (1) ______STUDENT (2) ______

Date of Birth ______DATE OF BIRTH______

ALLERIES/MEDICAL CONDITIONS______ALLERGIES/MEDICAL CONDITIONS______

______

MEDICATIONS______MEDICATIONS______

LEVEL OF EXPERIENCE______LEVEL OF EXPERIENCE______

IF STUDENT IS A MINOR:

PARENT/GUARDIAN NAME (S) ______

ADDRESS______

PHONE: CELL______HOME______WORK______

EMAIL ADDRESS______

EMERGENCY CONTACT INFORMATION: (Where applicable)

NAME______PHONE______RELATION TO STUDENT______

STUDENT NAME / INSTRUMENT / INSTRUCTOR / DAY / TIME / DEPOSIT

TOTAL ______

PAYMENT OPTIONS

A deposit of $110.00per ½ hour is due at the time of registration. We offer payment options as indicated below.

Please Check One:

□Plan A: One additional payment of $770.00 due on Sept 5th

□Plan B: Two additional payments of $385 due on Sept 5th and Jan 5th

□Plan C: Monthly payments of $110 beginning on Sept 5th and ending on March 5th

PLEASE COMPLETE NEXT PAGE

Total Deposit Due: ______

EXISTING CUSTOMERS:

□My Credit card information is the same, nothing has changed.

□Please process my card for the non-refundable registration fee.

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My credit/debit card information is as follows:

Please Circle: American Express MasterCard Visa Discover

Name of Cardholder: ______

Billing address: ______

Credit Card Number: ______Expiration Date:______

OR for automatic withdrawals from a checking account:

Bank/Institution Name:______

Bank Account Number: ______

Bank Routing Number: ______

If you prefer to pay by check, you may do so but please note that any payments received after the due date will be charged a $25 late fee. This fee will also apply to any declined credit card/bank transactions.

Also, please note that if paying by check there will be a $35 fee applied to any checks returned by a client’s banking institution.

*Please mark one

□Yes, I give permission for my child’s photography/video to be taken and posted, used for publicity and/or posted on the website.

□No, I do not give permission for my child’s photography/video to be taken and posted, used for publicity and/or posted on the website.

*Check the following 3 boxes to complete your registration

□I understand that a non-refundable deposit in the amount of $100(per ½ hour lesson) is required to register and hold my spot for next year.

□By checking this box, I acknowledge that I have read and thoroughly understand the Fiddlehead withdrawal/cancellation policies (this can be found on the website and summarized below)

  • A four lesson notice is required if you are to withdraw from the program before the end of the year. You will receive a prorated refund for the amount remaining after the four lesson notice date. The four weeks will start on the date you notify the Music Coordinator.

□I hereby release Fiddlehead Center for the Arts; its partners and all employees, agents, officers and volunteers from any liability claims, demands or suits for property damage and personal injury which could arise out of the course of participating in this program. I understand that these activities may involve physical exercise and a health risk and I will release all above mentioned parties from any claims. I also grant permission for emergency medical attention in case I am not able to be reached.

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Signature Date

Updated 1/19/2017