Student Agreement Form

Thank you for your interest in taking lessons at Lynchburg Music Center. Please fill out our Student Agreement Form to begin!

Once you have completed the form, please give us at call or stop by our store to schedule your first lesson and pay your tuition.

Address

6006 Fort Ave

Lynchburg, VA 24502

Phone

(434) 237-0073

Student First Name

Student Last Name

Age (if over 18, you may answer "adult")

If Under 18, Name of Parent/Legal Guardian

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Alternate Phone

Instrument/Class

I understand that completing this Agreement Form does not guarantee the availability for lessons with my desired instrument/instructor.

I understand that I must call or stop by Lynchburg Music Center to schedule lessons. Lesson appointments will not be reserved until payment is made for the first month.

I authorize Lynchburg Music Center (LMC) or its assigns to:

Photograph me and/or record my voice and likeness, digitally, or otherwise. Reproduce the original photos/recordings. Use my name, likeness, biographical information for education, promotions, or advertising, and for the sale of the photos/recordings.

Yes

I understand that LMC/assigns shall have complete ownership and rights of the photos/recordings. I give the right to use my name, likeness, and biographical information to publicize the programs and the services of LMC/assigns.

Yes

I understand that this right is given without consideration or compensation. There is no restriction to the number of times my name and likeness may be used.

Yes