Date:

06 November 2018

Gender:

Instrument:

Given Name:

Surname:

Post Code

Medical: Do you have any medical conditions (Eg Epilepsy, Asthma, ADD, Diabetes) that we should know about?

Level:

Given Name:

Surname:

Select Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Gender Female Male

Year of Birth

- Year - 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Year of Birth

Enter the times or time ranges that you are available for that day. Example 9:30am till 5pm.

Select Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Enter the times or time ranges that you are available for that day. Example 3:30pm till 9pm.

Contact Email:

Suburb:

Address:

Mobile Number:

Home Number:

Suburb:

Address:

Mobile Number:

Instrument Piano Ukelele Guitar Drums Vocal Violin Saxophone Flute Clarinet Trumpet

Home Number:

select Begginer Intermediate Advanced

Post Code

I give my consent to be contacted by Access Music by SMS.

I have read, understood and agree to abide by all above terms and conditions.

Relationship to the Student:

Please Select Mother Father Guardian Brother Sister Friend Husband Wife Partner

Student or Guardian Name:

Select Student (I'm over 18 years old) Guardian (I'm the legal guardian for the student)

Credit card Number:

Please deduct my

Visa Master Card Please select your Credit Card Type Amex & Visa Not Acceped Online

Expiry Month:

Please Select 01 02 03 04 05 06 07 08 09 10 11 12

Expiry Year:

Please Select 11 12 13 14 15 16 17 18 19

I am paying $350 inclusive of GST for 10 Individual Lessons as per conditions above.

Conditions of Application

1- Applicants are required to pay for the full term tuition prior to commencement of the term.

2- Fees are non-refundable once the applicant an us have agreed to a designated time and day to undertake lessons.

3- Applicants are responsible for attending weekly tuitions. In circumstances where this is not possible, please notify the academy within a reasonable timeframe (usually 24 hours).

4- Applicants undertaking individual tuition are eligible to arrange with their teachers ONE alternative (“make up”) lesson. Any further alternative arrangements are completely at the teacher’s discretion. Access Music Willetton is under no obligation to provide more than ONE alternative (“make up”) lesson.

5- Any changes to tuition times are to be made with the Administration of Access Music Willetton.

6- Access Music Willetton reserves the right to terminate this contract at any time.