Registration Form

Mirloo Music Academy

1353 Marine drive, West Vancouver, BC, V7T1B6

7786889234

mirloomusic@gmail.com

Basic Information

Student's Full Name

Student's Age

Student's Date of Birth

Year

Month

Day

Parent/Guardian Name (if the student is under 19)

*Please provide your full name as the parent or guardian (e.g., Mary/Mom, Gary/Dad)

Contact Information

Phone Number 1

Phone Number 2

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Information

Emergency Contact Name

Emergency Contact Phone Number

Allergies or Medical Conditions (optional but important for safety)

Music Experiences & Preferences

Requested Program (e.g., Piano, Violin, Voice Lessons, etc.)

Learning Goals (optional, e.g., RCM exams, fun learning, skill-building)

Previous Musical Experience (if applicable)

Additional Information

How Did You Hear About Mirloo Music?

Special Requests or Comments

Consent and Agreement to Terms and Conditions

By completing this registration form, I confirm that I have read, understood, and agreed to the Registration Rules and Policies outlined at [Registration]. I acknowledge that these terms govern lesson scheduling, cancellations, payments, and other Academy policies.

I understand that submitting this form constitutes my consent to adhere to these terms and conditions as part of my or my child’s enrolment at Mirloo Music Academy.

I, the undersigned, consent to Mirloo Music Academy capturing photographs and videos of my child during lessons and school activities. I understand that these images may be shared on the academy’s website, social media pages, and advertisements to celebrate and showcase the students’ achievements and promote the academy’s activities.

I give my consent.

Signature

Signature field is empty.

Parent/Guardian Name (if the student is under 19)

Student's Full Name

Today's Date

Year

Month

Day

CREDIT CARD AUTHORIZATION FORM

Mirloo Music Academy

1353 Marine drive, West Vancouver, BC, V7T1B6

7786889234

mirloomusic@gmail.com

Cardholder Information

Cardholder's Full Name

Card Type (check one)

Visa Card

Mastercard

Card Number (4 last digits)

Phone

Payment Authorization

Purpose of Payment

Payment Options (select one)

Recurring Payment Authorization (Based on a 4-month Contract)

One-Time Authorization

"Please note: By applying for recurring payment authorization, you will receive an invoice for each subsequent month, and the corresponding amount will be automatically charged to your account 10 days prior to the start of the lesson."

Please enter the monthly payment amount as specified in the invoice you received.

If you have selected the one-time authorization method, the amount will be withdrawn only once.

A 2% credit card processing fee applies to card payments.

Amount Authorized

"e.g. CA $192.60"

Authorization Statement

,authorize Mirloo Music Academy to charge my credit card for the amount listed above for the services provided. I understand that I am responsible for ensuring sufficient funds and that this authorization will remain in effect until the end of the contract.

Billing Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Signature

Signature field is empty.

Today's Date

Year

Month

Day

Parent/Guardian Information (if applicable)

Parent/Guardian Name

Student's Name

Violin

Viola

Cello

Music Accessories

Registration Form

Mirloo Music Academy

Basic Information

Contact Information

Emergency Information

Music Experiences & Preferences

Additional Information

Consent and Agreement to Terms and Conditions

CREDIT CARD AUTHORIZATION FORM

Mirloo Music Academy

Cardholder Information

Payment Authorization

Authorization Statement

Billing Address

Parent/Guardian Information (if applicable)

Contact information:

Business hour:

Follow Us

Fill out the form!