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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 *
Province/Territory *
Postal Code *
Postal Code
Birthdate of Student *
Birthdate of Student
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 *
Other Instrument Name
Other Instrument Name

Weekday(s) Available for Lessons *
Weekdays Available
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 *
Do you prefer lessons in person or online? *
In Person/Online
If anyone referred you, please type in their first and last name
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
I agree to purchase from Revolution Music International any instructional materials required for the lesson.
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 for the latest calendar. *
No refunds will be issued after the first lesson, including for materials sold.
I agree to not hold Revolution Music International, its locations, or any of the staff or teachers liable.
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.
If the student does not attend lessons, a video lesson will be given.
All video lessons will be a quarter to a third of the regular lesson time.
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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