Agreement - Music Therapy Connections

Studio Policy Agreement

Thank you for reading our studio policies handbook. Please complete the form below.

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*
Second Student's Name
(if applicable)
First Last
Second Student's Date of Birth
(if applicable)
Third Student's Name
(if applicable)
First Last
Third Student's Date of Birth
(if applicable)
Parent/Guardian*
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*