Lessons at the Music Lab
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Email *
Instructor Name: *
Student Name: *
Parent Name (or student if over 18): *
Parent Email (or student if over 18). This email will be used for invoicing: *
Parent Phone Number (or student if over 18): *
Address: *
Zip Code: *
City/County: *
Student Birthdate: *
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Part of our mission is to ensure lessons at The Music Lab are accessible to all students regardless of their financial situation. We have tried to establish a lesson rate that is affordable for many, but we understand everyone has a different situation.  Lessons are $30 for a half hour and $60 for a full hour. If this rate is not financially possible for you, please email jharman@jeffcenter.org. In your email state the reason for your need and how much financial assistance you require to make this opportunity a possibility for your student.  Our priority is that students have access to the resources that Jefferson Center can provide. Please select your lesson type below.
*
Demographic Information
Please note: Providing this information is optional. It does, however, help the Music Lab at Jefferson Center acquire grant funding for the program.
Race:
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Gender:
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Is English a second language?
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If so, please list them:
Media Release
I hereby grant Jefferson Center the right to use, reproduce, distribute and/or transmit photographs, videotape and/or recordings of my child, in whole and in part, and permit the use of their name in conjunction with these materials. I acknowledge that such photographs, videotape and/or recordings of me and any associated materials, printed, electronic, or other may become part of copyrighted materials that Jefferson Center may distribute to others in furtherance of its educational mission. If you prefer to opt out of the media release, please speak with Jordan Harman, Education Director, directly at 540-685-2309.
Do you agree to these terms? *
Emergency/Medical Information
First Contact Name: *
First Contact Relationship to Student: *
First Contact Phone Number: *
Second Contact Name: *
Second Contact Relationship to Student: *
Second Contact Phone Number: *
Please list any medical conditions, allergies, or other concerns of which we should be aware:
Thank you!
We are glad to have you at the Music Lab at Jefferson Center!
A copy of your responses will be emailed to the address you provided.
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