Lesson Registration Page 1 Page 2 Page 3 Page 4 Order Number Number of Students OneTwo Student One Name * Student Phone Number Student Email Allergies/Other Birth Date School Grade Instrument Years of Study Parent/Guardian * Phone 1 Phone 2 Email 1 Email 2 Physical Address Mailing Address City/State/ZIP Emergency Contact Name Phone Joel Bejot Music may take pictures, videos, or other likenesses of your children to use in promotional materials. Minors will not be named. Type your name to give consent, leave blank if consent is not given. Joel Bejot Music plans to share a Payment Plan? (Fall 2018 Tuition is $430 for 30-minute lessons) Paid in full by 9/13/2018 ($25 discount per student) 4 Equal payments Is there anything else you need to tell me?