AMPED Student Enrollment Form

How did you hear about us?*

What type of lesson(s) are you interested in?*

Skill Level*

BeginnerIntermediateAdvanced

Name of Student*

First Name Last Name

Date of Birth*

Date

Age*

Student is under 18 years oldStudent is over 18 years old

Name of Parent*

First Name Last Name

Parent Phone Number*

Area Code Phone Number

Parent Email*

example@example.com

Student Phone Number *

Area Code Phone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Additional Contact

First Name Last Name

Additional Phone Number

Area Code Phone Number

Additional Email

example@example.com

PAYMENT FOR MEMBERSHIP: Membership fees are due at the time of enrollment and will be automatically charged monthly by credit card or ACH. Lessons WILL NOT be scheduled in the instructional calendar until tuition has been paid or other arrangements have been made with AMPED management.

MEMBERSHIP SUSPENSION OR CANCELLATION: Memberships can be “suspended” or cancelled no later than 15 days prior to the next billing cycle. Requests for suspensions or cancellations must be requested in person. No refunds will be issued for remaining lessons in the previous billing cycle. Lesson slots will not be reserved while memberships are suspended. Membership rates will remain the same for a period of 90 days during the suspension, and after 90 days may be subject to increase.

If you need to cancel your lesson:

- Call us at (661) 729-2673 NO LATER THAN FIFTEEN (15) MINUTES PRIOR TO YOUR SCHEDULED LESSON. If no one answers the phone, leave us a voice mail message. Please do not email or message your teacher (unless you are doing online lessons)

- We do not do "Make-up" lessons. Instead, you will receive an individualized home study lesson within 24 hours from your teacher (in your student portal on Teacher Zone) that you can access at any time from any internet-connected device.

LATE ARRIVAL: Our teachers have reserved their time for you and will be ready at your scheduled lesson time. Please arrive to your lesson at least 10 minutes early so that you can be ready to start on time. Please call the front desk if you are going to be late. If we do not receive prior notification, after 15 minutes that lesson will be forfeit and marked in the system as “No Show”. Late arrivals and no shows are not eligible for home study lessons.

SUBSTITUTE TEACHERS: Students at AMPED are taught by faculty who work in the music scene. This allows them to bring the highest caliber of real-life experience to their students. If your teacher has a gig or is going on tour, you will be provided with an equally capable teacher in their absence. In the case of teacher absence or vacation, you will be offered a substitute teacher for that lesson, if available. If no teacher is available, your lesson will be rescheduled or refunded.

ILLNESS: In order to keep your teachers and the other students healthy, we ask that you cancel your lesson if the student is contagious. As long as you cancel within 15 minutes prior to your lesson, you will receive a home study lesson to use at any time.

FAMILY VACATIONS: If you have a family vacation planned and wish to have your recurring billing temporarily suspended while you are on vacation, you will need to let us know at least 30 days prior to the start of your vacation so that we can alert your bank. If you suspend your tuition we cannot save your lesson day/time slot.

SUPERVISION: Students under the age of 12 may not be left unattended during their lessons or while using practice rooms and must be accompanied by a legally responsible adult. Students 12-17 years of age must be picked up at the time their lesson is over (unless prior arrangements are made with the front desk). AMPED is not liable for students left unattended before or after lessons, and late pick-up may be subject to full lesson fee.

HOLD HARMLESS AGREEMENT: I understand and acknowledge that listening to loud music over time has the potential to lead to hearing loss. For this reason, AMPED recommends that students purchase personal protective hearing devices to use during any lessons or rehearsals that are amplified. Protective hearing devices are not required by AMPED. However, AMPED recommends purchasing and using earplugs during lessons and rehearsals. By signing below, you acknowledge that you are aware of the potential harmful effects of listening to music at loud volumes and agree to hold the Academy of Music Performance aka AMPED harmless for any and all injury whether temporary or permanent.

I UNDERSTAND AND AGREE TO THE POLICIES ABOVE*

Yes

My selection below verifies agreement that I, for myself and any minor children for which I am responsible, any heirs, personal representatives or assignees, do hereby release the Academy of Music Performance and Education aka AMPED, its principals, directors, officers, agents, employees, and volunteers from any and all liability, and waive any claims for damage arising from any cause whatsoever. I further agree to reimburse the Academy of Music Performance and Education aka AMPED for all attorneys’ fees and costs should I bring legal actions against the Academy of Music Performance and Education aka AMPED.

I UNDERSTAND AND AGREE TO THE WAIVER AND RELEASE ABOVE*

Yes

At AMPED, we are following the Los Angeles County health guidelines for indoor businessess.

Students and visitors will enter through the back door and scan their temperature for fever. If temperature is above 100.1*, students will be required to reschedule their lesson.

Students and visitors will be required to wash hands with soap and water, or use hand sanitizer prior to entering the main building.

Face Coverings will be required only if county mandates are in place. If you prefer your teacher wear a face covering, please let us know and we will be happy to accomodate that request.

Teachers will be sanitizing instruments before and after each lesson.

My selection below verifies agreement that I, for myself and any minor children for which I am responsible, any heirs, personal representatives or assignees, do hereby release the Academy of Music Performance and Education aka AMPED, its principals, directors, officers, agents, employees, and volunteers from any and all liability, and waive any claims for damage arising from any cause whatsoever. I further agree to reimburse the Academy of Music Performance and Education aka AMPED for all attorneys’ fees and costs should I bring legal actions against the Academy of Music Performance and Education aka AMPED.

I UNDERSTAND AND AGREE TO THE HEALTH AND SAFETY POLICIES ABOVE*

Yes

Filming and taping take place frequently at AMPED.

Posting student lessons, rehearsals and performances via photos and videos on our website, Facebook Page and promotional materials helps us promote the positive image of our school.

By agreeing to this authorization, you allow AMPED to use any likeness, image, or recording of you, or any children for whom you are responsible, obtained through these practices.

I UNDERSTAND AND AGREE TO THE FILMING AND RECORDING AUTHORIZATION AND RELEASE*

YESNO

Will you be using Charter School Funds?*

YesNo

What is the name of the charter school:ex: Gorman Learning Center*

Please Note: Tuition for charter students is $300 per month.

(This amount includes any 5th week of lessons that occur in the month).

Lessons are one hour per week.

We are unable to schedule or begin lessons until we receive a purchase order or certificate directly from the school). (This is per our contract with your charter school).

Who is the Financially Responsible Party*

First Name Last Name

I, authorize AMPED to charge $ Tuition Amount* to my credit card or bank account on file on the day of the month below:

Auto Withdrawl Date of Each Month

I understand that if one of my lessons happens to fall on a 5th week in a payment cycle, I acknowledge that an additional charge of $60 will be added to my monthly payment.

I authorize Academy of Music Performance and Education (AMPED) to charge the credit card or bank account I have provided to them according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it directly with the business owners. I agree to notify the business owner's of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above and will appear on your bank statement as ECS (Electronic Cash Systems). I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

Signature*

Clear

We will contact you by phone to process your payment

Phone Number

Area Code Phone Number

Student Enrollment Form

AMPED POLICY AGREEMENT

LIABILITY WAIVER AND RELEASE

HEALTH POLICIES AND PROCEDURES

FILMING AND RECORDING AUTHORIZATION AND RELEASE

FINANCIAL AGREEMENT