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Email *
What is the name of the payee? *
Payee's Name
What is the name of the student? *
Student's Name
Phone number *
Phone Number
Street Address *
Street Address
City *
City
Province/Territory *
Province/Territory
Postal Code *
Postal Code
Birthdate of Student *
Birthdate of Student
MM
/
DD
/
YYYY
Gender of student *
Is there anything about the student that we should know in advance (i.e. medical conditions, etc.) and what we should do?
Emergency Contact Name and Phone Number *
Instrument(s) for Lessons *
Instruments
Required
Other Instrument Name
Other Instrument Name

Weekday(s) Available for Lessons *
Weekdays Available
Required
Does the student own the instrument already? Note: They will need to own/rent their instrument before the second lesson. *
Do you wish for a 3-lesson trial package?  No commitment is necessary, but only one package is allowed per household.
Time(s) Available *
Times Available
What is the preferred length of the weekly lessons? (To find out prices, go to www.revolutionmusicint.com/pricing) *
Do you prefer lessons in person or online? *
In Person/Online
If anyone referred you, please type in their first and last name
Referral
Referral's Email Address
Contact for Referral
If there was a coupon code that was given to you, please type it in.
If payments returns NSF, there will be a late charge of %10
*
Required
I agree to purchase from Revolution Music International any instructional materials required for the lesson.
*
Required
If a holiday weekend falls on your regular lesson day, a video lesson will be given instead.  If there is any questions about calendar dates, please go to www.revolutionmusicint.com/calendar for the latest calendar. *
Required
No refunds will be issued after the first lesson, including for materials sold.
*
Required
I agree to not hold Revolution Music International, its locations, or any of the staff or teachers liable.
*
Required
If the student is sick, they should not attend lessons.  Instead phone the teacher in advance, so they can make a video lesson for the student.
*
Required
If the student does not attend lessons, a video lesson will be given.
*
Required
All video lessons will be a quarter to a third of the regular lesson time.
*
Required
I agree to give at least 30 days notice before quitting lessons (unless it is only a trial package). If the payment date is less than 30 days away, it will still be taken out, as it is on a subscription basis, but the lessons after the "30 day" period will be refunded.
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Required
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