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Registration
Registration & Auto-Pay Authorization
Student's Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Musical Instrument & Lessons' Duration
Lessons' Location
(Required)
In-Home Lessons
Online Lessons
Instrument
(Required)
Choose Instrument
Singing
Piano
Piano & Singing
Guitar
Guitar & Singing
Ukulele
Drums
Brass & Woodwinds
Strings
Music Production
Teacher's Name
Lesson's Duration:
(Required)
60 Minute Lessons. Monthly Tuition: $303 (based on $70 per lesson. 4.33 lessons a month on average)
45 Minute Lessons. Monthly Tuition: $238 (based on $55 per lesson. 4.33 lessons a month on average)
30 Minute Lessons. Monthly Tuition: $195 (based on $45 per lesson. 4.33 lessons a month on average)
Online Lesson's Duration:
(Required)
60 Minute Online Lessons. Monthly Tuition: $281 (based on $65 per lesson. 4.33 lessons a month on average)
45 Minute Online Lessons. Monthly Tuition: $217 (based on $50 per lesson. 4.33 lessons a month on average)
30 Minute Online Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Add additional student/s in the same household
Not Applicable
Add ONE Student
Add TWO students
Additional Student (#2)
(Required)
First
Date of Birth (#2)
(Required)
MM slash DD slash YYYY
Musical Instrument & Lessons' Duration (#2)
Lessons' Location (#2)
(Required)
In-Home Lessons
Online Lessons
Instrument (#2)
(Required)
Choose Instrument
Singing
Piano
Piano & Singing
Guitar
Guitar & Singing
Ukulele
Drums
Brass & Woodwinds
Strings
Music Production
Teacher's Name (#2)
Lesson's Duration (Student #2):
(Required)
60 Minute Lessons. Monthly Tuition: $303 (based on $70 per lesson. 4.33 lessons a month on average)
45 Minute Lessons. Monthly Tuition: $238 (based on $55 per lesson. 4.33 lessons a month on average)
30 Minute Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Online Lesson's Duration (Student #2):
(Required)
60 Minute Online Lessons. Monthly Tuition: $281 (based on $65 per lesson. 4.33 lessons a month on average)
45 Minute Online Lessons. Monthly Tuition: $217 (based on $50 per lesson. 4.33 lessons a month on average)
30 Minute Online Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Additional Student (#2*)
(Required)
First
Date of Birth (#2*)
(Required)
MM slash DD slash YYYY
Musical Instrument & Lessons' Duration (#2*)
Lessons' Location (#2*)
(Required)
In-Home Lessons
Online Lessons
Instrument (#2*)
(Required)
Choose Instrument
Singing
Piano
Piano & Singing
Guitar
Guitar & Singing
Ukulele
Drums
Brass & Woodwinds
Strings
Music Production
Teacher's Name (#2*)
Lesson's Duration (Student #2*):
(Required)
60 Minute Lessons. Monthly Tuition: $303 (based on $70 per lesson. 4.33 lessons a month on average)
45 Minute Lessons. Monthly Tuition: $238 (based on $55 per lesson. 4.33 lessons a month on average)
30 Minute Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Online Lesson's Duration (Student #2*):
(Required)
60 Minute Online Lessons. Monthly Tuition: $281 (based on $65 per lesson. 4.33 lessons a month on average)
45 Minute Online Lessons. Monthly Tuition: $217 (based on $50 per lesson. 4.33 lessons a month on average)
30 Minute Online Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Additional Student (#3)
(Required)
First
Date of Birth (#3)
(Required)
MM slash DD slash YYYY
Musical Instrument & Lessons' Duration (#3)
Lessons' Location (#3)
(Required)
In-Home Lessons
Online Lessons
Instrument (#3)
Choose Instrument
Singing
Piano
Piano & Singing
Guitar
Guitar & Singing
Ukulele
Drums
Brass & Woodwinds
Strings
Music Production
Teacher's Name (#3)
Lesson's Duration (Student #3):
(Required)
60 Minute Lessons. Monthly Tuition: $303 (based on $70 per lesson. 4.33 lessons a month on average)
45 Minute Lessons. Monthly Tuition: $238 (based on $55 per lesson. 4.33 lessons a month on average)
30 Minute Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Online Lesson's Duration (Student #3):
(Required)
60 Minute Online Lessons. Monthly Tuition: $281 (based on $65 per lesson. 4.33 lessons a month on average)
45 Minute Online Lessons. Monthly Tuition: $217 (based on $50 per lesson. 4.33 lessons a month on average)
30 Minute Online Lessons. Monthly Tuition: $173 (based on $40 per lesson. 4.33 lessons a month on average)
Home Address
(Required)
Street Address
City
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Texas
Utah
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Virginia
Washington
West Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Email (for Notices & Billing)
(Required)
Mother's Name
Mother's Full Name
Mother's Phone Number
Father's Name
Father's Full Name
Father's Phone Number
Payment Information
I would like to pay using my:
(Required)
Credit or Debit Card
ACH (Bank Account)
Cardholder's Name
(Required)
First
Last
Credit/Debit Card Number
(Required)
Expiration
(Required)
CVV
(Required)
Card's Billing Address
(Required)
Same as Home Address
Different Address
Card's Billing Address
(Required)
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Bank Account's Holder Name
(Required)
First
Last
Bank's Routing Number
(Required)
nine-digit number printed in the bottom left corner of each check
Checking Account Number
(Required)
Bank account numbers are usually between nine to twelve digits, although some may be longer. it is printed in the middle or right corner of each check. Please do not include the check number.
Consent
(Required)
I agree to the terms of this registration form:
As a duly authorized signer of the financial institution account identified above, I allow California Music Academy/GoldPass Music to perform scheduled or periodic electronic debits to my credit/debit card or my checking account specified above.
All tuition payments are made by pre-authorized monthly auto-debit. Tuition charges will be debited to the bank account or credit/debit card on file on the 1st day of each month. Monthly tuition charges are based on the rates effective on the billing date. The auto-debit system will automatically email a receipt every 1st of the month directly to your email address on file. If you register in the middle of the month, your monthly tuition for that specific month will be pro-rated and charged as a one-time payment, along with the $25 annual registration fee per student. A minimum of 30-day written notice via email is required to discontinue lessons. 24-hour notice is required for cancellation or rescheduling of any lessons. Canceled lessons can be made up based on teachers' availability and cannot be applied as a credit toward future billing cycles. The initial payment may be charged to your account when our office processes your registration request.
Authorized Signer Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Signature
Email
This field is for validation purposes and should be left unchanged.
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