Affiliate Form

Date*

Student Name*

First Last

Preferred Name/Pronoun

DOB*

Race*

This is used for grant funding purposes only

Ethnicity*

Hispanic

Non-hispanic

Decline to answer

This is used for grant funding purposes only

School Status*

Name of School Student Currently Attends:*

Are you a returning student?*

Yes

No*

How did you hear about us?

Instrument*

Years of Music Study:*

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Parent or Guardian's Name*

First Last

Parent or Guardian's Name

First Last

Parent or Guardian's Primary Phone Number*

Student's Phone Number

Primary Email*

Optional Secondary Email

Name of Emergency Contact*

Relationship to Student*

Emergency Contact Phone*

A payment must be made prior to the start of the semester for a student to be officially registered. Teachers are contracted for an entire semester and must be paid regardless of the discontinuation of lessons mid-semester for any reason. Please note, this form will only be for the $35 affiliate fee. The full lesson cost is separate and must be paid to the individual private teacher through their preferred methods. By reading this statement, you acknowledge that you are committed to paying for the full semester and that you have read our policies and procedures.

I consent and will abide by the above statement.*

Yes

No

I give permission to the Academie Musique to use pictures of my child for possible use on social media and website.*

Yes

No

Academie teacher you are studying under*

Emily Baker

Shelley Dennis

Erin Gibson

Other

Total

Payment can be brought to the Academie Musique Office, 3001 Meadow Oaks Dr. Monday-Thursday 2:30-6:30pm and Friday 3-6:30pm, paid online through QuickBooks or mailed to:

Academie Musique
3001 Meadow Oaks Dr., Temple, TX 76502

Donation to our Scholarship Fund and Moving Costs (Tax deductible)

$5

$20

$50

Other

If you select "Other" donation, please enter an amount and the amount will be added to the invoice and sent back to you.

Registration Fee

Price:

Donation $5

Price:

Donation $20

Price:

Donation $50

Price:

Anything else we should know?

Total

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