Registration Form – Spring 2012
Name of student: __________________________________________ 
Street Address: ____________________________________________
City: ______________ State: ______________Zip: _______________
Phone: ______________________ Cell Phone:___________________
 Grade in school: _________________Date of Birth:________________
Parent’s name: _____________________________________________
Email Address: _____________________________________________
    Emergency phone: __________________________________________
Important Medical  Information: _______________________________
Instrument:___________ Teacher:_____________ Starting date:______
	    Lesson day and time:_________________________________________
Registration, Cancellation and Refund Policy			  	  
Cancellations and make-up lessons		
Two private lessons per semester will be made-up. All cancellations must be made 24-hours in advance
in order to be made-up. If a cancellation is made 
without 24-hour notice no make-up will be given.
All cancellations due to illness must be made before 10:00 a.m.
In order to receive a make up. Two opportunities will be offered 
for each make-up. If both are refused the lesson will be 
considered made-up. If a student cancels their scheduled  make-up 
lesson, they may not be rescheduled, the lesson will be considered 
made-up. A qualified substitute can be sent in case of teacher absence.
No makeup lessons will be carried over into the next semester.
It is your responsibility to schedule any make-up lessons.
	Tuition 1:____________
Tuition 2: ____________
Registration Fee:  $55.00
Total: _______________
Payment: _____________

 	Billing zip code if different:
Registration fees are non-refundable. A Larchmont Music Academy credit will be applied to any withdrawal from individual instruction or classes until the fourth week of the semester on a pro-rated basis. 
However, no credit will be issued after the fourth week of classes, except in cases of prolonged illness.  Tuition is fully refunded if the student withdraws before the first class or lesson. There are no refunds after the first lesson or class. 
LMA is not responsible for lost or stolen property. My child’s 
picture may be used for publicity purposes. Additional fees may be incurred for materials (books etc.) necessary for lessons. 
To ensure continuity of your musical education your registration is ongoing. You will be automatically registered and charged for each consecutive semester during the school year unless we receive written or emailed cancellation. This does not apply to the summer sessions.	
I have read and understood the
Registration, cancellation and refund policy:  

Signature:________________________

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