Agreement - Music Therapy Connections

Policy Agreement Statement

Yes, I agree to the policies as written in the studio handbook. I have read the policies in their entirety and will adhere to them as a student and/or parent/guardian of a student.

If you have additional questions or concerns regarding the studio policies, please contact us directly via email, info@musictherapyconnections.org.

Student's Name*

First Last

Date of Birth*

Type of Service*

Second Student's Name

(if applicable)

First Last

Second Student's Date of Birth

(if applicable)

Type of Service

Third Student's Name

(if applicable)

First Last

Third Student's Date of Birth

(if applicable)

Type of Service

Fourth Student's Name

(if applicable)

First Last

Fourth Student's Date of Birth

(if applicable)

Type of Service

Fifth Student's Name

(if applicable)

First Last

Fifth Student's Date of Birth

(if applicable)

Type of Service

Parent/Guardian's Name

(if student(s) under age 18)

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Media Release*

Photos and videos may be used for promotional purposes on our website, social media, and print materials. If you do not grant permission, photos and videos of you/your student(s) will not be used outside of the studio for any reason.

Special Considerations

Please list any allergies, special needs, or other issues so that you/your student(s) can be best served during lessons, sessions, and classes.

Referral Source

If you heard about Music Therapy Connections from a current student or family member of a current student, please list his or her name below so that they receive referral credit.

Payment Information

Preferred form of payment is auto withdrawal from a checking or savings account. The information you enter below is kept secure via SSL encryption. Auto withdrawals are made on the 15th day of each month. Upon submission of this form and before your first payment is collected, you will receive an email confirming your tuition amount.

Routing Number*

Account Number*