Belmont Academy Registration

Belmont Academy Registration
Semester of Study:*

FallSpringSummer
Lesson Type Preference*

In-PersonOnline
Student's Name:*

First Name Last Name
Student's Age:*
Date of Birth:*
School Attended:*
Parent/Guardian:*

First Name Last Name
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Phone:*
Alternate Phone:
E-mail (for receipt):*

Confirmation Email

Emergency Contact/Approved Caretakers
Emergency Contact:*

First Name Last Name
Emergency Contact Phone:*
If under 12 years of age, student must be picked up by an approved caretaker, unless waived by the parent or guardian.
List the names of those approved to pick up student:*
By waiving this policy, I acknowledge that Belmont Academy and its instructors are not required to obtain an approved signature before my child leaves their lesson.

By not waiving this policy, I (or an approved caretaker) must sign my child in and out at the beginning and end of each lesson.
Waiver (I have read and agree to the policy):*

I waive the responsibility of escorting my child to and from their lessons.I, or approved caretaker, will sign my child in and out of their lessons.

Lesson Registration
Instructor:*
Instrument of Study:*
Lesson Day/Time:*
Lesson Length:*

30 min45 min1 hr
Number of Lessons (n/a for Suzuki students):
Suzuki Violin:

Pre-TwinkleBook I/IIBook III/IV
Please read the policies located at: http://www.belmontacademy.net/bahome/policies.html, and confirm that you have done so by checking the box below. Agreement must be read and checked in order to move forward with processing. Each student must register separately. If you have questions regarding your tuition, contact Belmont Academy at 615-460-6346. Approval from the office must be given in order to register for a lesser amount of lessons.
Policy Agreement:*

YesNo

Photo Release
Photo Release Agreement:*

YesNo
Belmont Academy
Photo and Video Release
Participant Name(s):

Participant 1 Legal Name: * Preferred Name: *
Participant 2 Legal Name: Preferred Name:
Participant 3 Legal Name: Preferred Name:
I understand that Belmont University may take photographs or video images of Belmont Academy activities which may include the participant.

I hereby give Belmont University, its employees, licensees, and agents, the absolute and irrevocable right and permission with respect to photographs or video images taken of the participant or in which the participant may be included with others to:

• copyright the photograph/video/audio footage in the university’s name or university photographer/videographer’s name.

• use, re-use, publish and republish the same in whole or in part, individually or in conjunction with other photographs/footage, in any medium, including broadcast over the Internet, for instructional and promotional use of the university.

I hereby release and discharge Belmont University, its trustees, officers, employees, licensees and agents from any and all claims and demands arising out of or in connection with the use of the photographs or video footage, including all claims for invasion of privacy and appropriation.

This authorization and release shall also ensure to the benefit of the legal representatives, licensees, and assigns of Belmont University.

Statement of Understanding
I, Signature* , warrant that I am the parent or legal guardian of the participant listed above and have the authority to complete this registration on behalf of the participant.

Signed,
Name: Full Name* Sign Name: Signature* Date: Date*

Credit Card Payment Information
Credit Card Fee:*

5.00
Tuition Amount:*
Calculation

Total Tuition Amount:*

USDTuition Amount:

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please verify that you are human*
Should be Empty:

Belmont Academy Registration

Emergency Contact/Approved Caretakers

Lesson Registration

Photo Release

Credit Card Payment Information