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ENSEMBLE ARTS ACADEMY
4040 N TENAYA WAY
LAS VEGAS, NV 89129
TEL (702) 388-0014 FAX (702) 388-0018
Email: musicborders@cox.net
STUDENT ENROLLMENT FORM
Student Name:
Last: ___________________________________ First: __________________________________
Age: _________ Birth Date: ____________________________________________________________________
Lesson Start Date: ______________________________ Lesson Day: ___________________________________
Lesson Time: ________________ Teacher: __________________________ Instrument: ____________________
Registering for (Please check all that apply):
Solo Lessons: ❑ 30-minute solo lesson ($115/mo) ❑60-minute solo lesson ($230/mo)
Duet Lessons: ❑ 60-minute duet lesson ($149/mo/per student): Student partner preferred: __________________________
Ensemble Lessons: ❑ 60-minute lesson ($119/mo/per student): Student partners preferred: List
Parent’s Last Name (if different): ________________________________________________________________
Mother's First Name: ____________________________ Father's First Name: _____________________________
Home Phone: ____________________________________ Cell Phone: __________________________________
Work Phone: _______________________________________
Home Address: ______________________________________________________________________________
City: _____________________________________________ State: ________Zip Code: ___________________
E-mail Address: ______________________________________________________________________________
How did you hear about Ensemble Arts Academy? Circle any that apply:
1. Dex Yellow Pages 3. Las Vegas Kids Directory 4. www.SchoolMusicSource.com
5. www.EnsembleArtsAcademy.com 6. Walk-in 7. Referral 8. Craigslist 9. Other: ________________________
Authorized Signature: ________________________________________________________________________
AUTO DEBIT PAYMENT CONSENT
I hereby authorize Ensemble Arts Academy to charge my credit/debit card the amount of $_________ on the first day of each month. All charges will appear as Ensemble Arts Academy. I understand that I may cancel this Debit Authorization by providing written notice to Ensemble Arts Academy one month or more prior to the payment due date. I further understand that canceling my Debit Authorization does not relieve me of the responsibility of paying my account in full. Only recurring monthly lessons fees will be collected via automatic payment. Incidental fees such as instrument rentals, accessories, and music books must be paid for with cash, check, or credit card in a separate transaction.
Method of Payment (Circle One): Visa MasterCard
Card Number (16 digits): _____________________________________________________________________
Expiration Date: ____________________________________ CVV# (back of card) ______________________
Cardholder's Name (Print): ___________________________________________________________________
Authorized Signature: ________________________________________________________________________
Date: ______________________________________________________________________________________
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