Group Classes Enrollment

Please complete each field or enter N/A when not applicable.

Step 1: Student Information

EMAIL CONTACT:
PHONE CONTACT:
Student Name:
DOB:
School:
Grade Fall 2011 (or year to enter Kindergarten)
Address:
City:	State: Zip:
Additional Cell/Emergency phone:
Parent(s) Name:
Other Information (ie: allergies):
How did you hear about us?

2: Activity SELECTION

Select Class

Select Session (Day & Time)

3: Payment Options

PERSONAL CHECK Payable to Milder Musical arts, students' place reserved when payment is received

AUTOPAY: ELECTRONIC DEBIT Safe, easy and convenient

Routing Number:

Account Number:

AUTOPAY: CREDIT/DEBIT CARD Add'l 3% Processing Fee

Credit/Debit Card Number:

Exp. Date

Type:

$25 Fee for Returned Check or Declined Electronic Funds

4: Tuition Due

Tuition Subtotal		$
Materials Deposit		$
Registration Fee	New students only, current students pay annual registration/deposit fee May	$
TOTAL TUITION DUE:		$

When tuition is received, enrollment is processed and commitments are made to teachers.
I understard that when payment is received, tuition becomes non-refundable and non transferable.