Registration Form | GoldPass Music

Registration & Auto-Pay Authorization

URL

This field is for validation purposes and should be left unchanged.

Student's Name(Required)

Date of Birth(Required)

Musical Instrument & Lessons' Duration

Instrument(Required)

Teacher's Name

Lesson's Duration:(Required)

Add additional student/s in the same household

Additional Student (#2)(Required)

Date of Birth (#2)(Required)

Musical Instrument & Lessons' Duration (#2)

Instrument (#2)(Required)

Teacher's Name (#2)

Lesson's Duration (Student #2):(Required)

Additional Student (#2*)(Required)

Date of Birth (#2*)(Required)

Musical Instrument & Lessons' Duration (#2*)

Instrument (#2*)(Required)

Teacher's Name (#2*)

Lesson's Duration (Student #2*):(Required)

Additional Student (#3)(Required)

Date of Birth (#3)(Required)

Musical Instrument & Lessons' Duration (#3)

Instrument (#3)

Teacher's Name (#3)

Lesson's Duration (Student #3):(Required)

Home Address(Required)

Email (for Notices & Billing)(Required)

Mother's Name

Mother's Phone Number

Father's Name

Father's Phone Number

Payment Information

I would like to pay using my:(Required)

Credit or Debit Card

ACH (Bank Account)

Cardholder's Name(Required)

Credit/Debit Card Number(Required)

Expiration(Required)

CVV(Required)

Card's Billing Address(Required)

Same as Home Address

Different Address

Card's Billing Address(Required)

Bank Account's Holder Name(Required)

Bank's Routing Number(Required)

nine-digit number printed in the bottom left corner of each check

Checking Account Number(Required)

Bank account numbers are usually between nine to twelve digits, although some may be longer. it is printed in the middle or right corner of each check. Please do not include the check number.

Consent(Required)

I agree to the terms of this registration form:

By signing and submitting this registration form, I confirm that I am authorized to use the credit or debit card provided, or am a duly authorized signer on the checking account provided. I authorize GoldPass Inc. dba GoldPass Music and its payment processor to initiate scheduled or periodic electronic charges to my credit or debit card, or debits to my checking account, for tuition and the annual registration fee described below.

--- Tuition and Billing ---

All tuition payments are made by preauthorized monthly automatic debit. Tuition is charged to the credit or debit card, or debited from the checking account, on file on the first day of each month. An electronic receipt is automatically emailed to the email address on file when each payment is processed.

Monthly tuition will be calculated using the tuition rate in effect on the billing date. GoldPass will provide advance written notice before changing a student’s tuition rate.

If lessons begin after the start of a month, tuition for that month will be prorated based on the student’s start date and scheduled lessons. Prorated tuition for the initial month is collected as a one-time payment, together with the $25 annual registration fee for each student. GoldPass may charge this initial payment when the office processes the registration request. The registration fee will be charged at enrollment and annually thereafter. Unused tuition is not eligible for a credit or refund.

This authorization will remain in effect until enrollment ends and all outstanding amounts have been paid. I may revoke this payment authorization by giving GoldPass written notice by email. Revoking the payment authorization does not, by itself, cancel enrollment or eliminate amounts already owed.

--- Discontinuing Lessons ---

At least one month’s written notice by email to GoldPass is required to discontinue lessons. Tuition remains due for lessons scheduled during the notice period, whether or not the student attends. The effective cancellation date will be confirmed by GoldPass in writing.

--- Lesson Cancellations and Makeups ---

At least 24 hours’ notice is required when requesting to cancel or reschedule a lesson. Lessons canceled with at least 24 hours’ notice may be made up, subject to the instructor’s availability. Makeup lessons are not guaranteed, have no cash value, and cannot be used as a credit toward future tuition payments.

Lessons missed or canceled with less than 24 hours’ notice will be charged as scheduled and are not eligible for a makeup lesson, except in an emergency or when otherwise approved by GoldPass.

If GoldPass or the instructor cancels a lesson, GoldPass will arrange a makeup lesson or provide an appropriate tuition credit, unless the teacher makes up the canceled lesson/s.

--- Electronic Consent ---

By electronically signing and submitting this form, I acknowledge that I have read and agree to the tuition, billing, cancellation, and makeup policies stated above. My electronic signature has the same effect as a handwritten signature. I authorize GoldPass and its payment processor to initiate the recurring charges described in this agreement and to send payment receipts and related notices electronically.

Authorized Signer Name(Required)

Date(Required)

Signature