Automatic Payment Consent Form

REGISTRATION FORM/AUTOMATIC PAYMENT CONSENT FORM

Last Name:______Parent’s Name:______

Students Name

Student Birth-date

Instrument/Class

Lesson Day & Time □30 □45 □60 □30 □45 □60 □30 □45 □60 □30 □45 □60 Lesson Length

Teacher

Date Starting Lesson

Phone #: ______Work/Emergency Phone #: ______

Address: ______Street City Postal Code

Where they heard about us:  CS  DH  YP  HV  Post Card  Sign  Internet  Newspaper  Website

 Referral______ Other______Email Address:______

Date Registered:______Employee Signature:______

Method of Payment *All charges will appear on your bank or credit card statement as Utah Conservatory*

Visa  MC  Amex ______Card Number Expiration Date

Card Holder’s Name ______CVV#______Billing Zip______

I hereby authorize The Utah Conservatory to charge my account in the amount of

$______on the 20th day of each month starting______and ending, ______.

Including a  $30.00  $50.00  All ready paid Registration fee to be charged immediately.

First Month’s Fee: ______Ongoing Monthly Fee: ______

I have reviewed and agree to the monthly tuition, reschedule policy, withdrawal policy, school policies and procedures.

X______Signature Date

Employee Signature:______Input / Constant Contacts/ File Date:______

Utah Conservatory 4593 Silver Springs Dr. Park City, UT 84098 435-649-6292 [email protected]

Policies and Procedures

Registration: A non-refundable fee of $30 per student or $50 per family is required yearly at time of registration. There is no registration fee for the summer semester.

Payment of Fees: Tuition must be paid by automatic debit or automatic credit card payment. Tuition will be charged on the 20th of each month. Payment must be made by pre-authorized automatic monthly payment, or paid in full.

Withdrawal Policy: If you would like to withdraw from weekly lessons, you must submit a written letter, email, or withdrawal form to the office, 15 days prior to the last lesson. Tuition will be pro-rated accordingly for lesson after the 15 day window. There are no credits given if lessons within the 15 days are not be taken, or rescheduled.

Extreme Weather or Unexpected Interruption of Classes: If the school must cancel classes due to extreme weather or events beyond our control such as power outages, the missed lessons will be added on to the end of the teaching year. No refunds for lessons missed due to these reasons will be given.

Substitutions: The school reserves the right to provide a substitute teacher if the regularly scheduled teacher is ill or otherwise unable to teach a lesson. If the school cannot arrange a substitute, any school missed classes may be rescheduled, or refunded according the wishes of the client. Refunds for the teacher misses will be issued in the form of a lesson credit (tuition reduction) on the next month’s charge.

Reschedule Policy: If an appointment isn’t rescheduled, the school will compensate the teacher for their time. Clients are allowed to ‘reschedule’ a lesson under the following criteria: 1) 6 hour notice must be received via e-mail or phone (leave a message). 2) It is the responsibility of the client to find another time, before the time of the lesson being rescheduled. No reschedules will be given after the lesson has passed. 3) Rescheduled lesson must be done in a teacher ‘gap’ or ‘cancellation’, not extending their teaching day.

Parent’s Responsibility to be Aware of Dates and Events: It is the responsibility of the parent or adult student to be aware of all school activities, such as viewing days, recitals, extra classes, and dates the school is open or closed. The school will post all such notices on the bulletin board, and via constant contact e-mails. It is the responsibility of the parents or adult students to inform the school of any billing, address, e-mail or telephone number changes.

Care of Students: The school is not responsible for providing before or after class care for students. Parents with students under the age of 6 are to remain in the school during classes. Students are not to be left at the school for excessive time before or after class, but are welcome to hang out to practice music.

Injuries: Parents, legal guardians of minor students and adult students waive the right to any legal action for any injury sustained on school property resulting from activity conducted by the students before, during or after class time.

Photo Release: The school is hereby granted permission to take photographs of the students to use in brochures, web sites, posters, advertisements and other promotional materials the school creates. Permission is also hereby granted for the school to copyright such photographs in its name.