Music Motive Online Registration

Registration

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Welcome! Our system is designed to relieve tasks from your instructor so that they can focus solely on teaching. We want to do our best to serve you so please take a moment to understand how our program works by reading our policies and procedures at the end of this form. Thank you!

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Student's Last Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (if none, leave blank)

Special Needs (if none, leave blank)

Allergies (if none, leave blank)

All classes are displayed with the discounted monthly tuition rate for private lessons or the session fee for groups. If you prefer a single private lesson, or have other information/requests, please enroll and use the comments section or call/text 805-543-0377 to let us know. Please note that your card is NOT automatically charged upon submission of the registration.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (if none, leave blank)

Special Needs (if none, leave blank)

Allergies (if none, leave blank)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (if none, leave blank)

Special Needs (if none, leave blank)

Allergies (if none, leave blank)

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (if none, leave blank)

Special Needs (if none, leave blank)

Allergies (if none, leave blank)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

Disabilities (if none, leave blank)

Special Needs (if none, leave blank)

Allergies (if none, leave blank)

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)