Student's Name *
Student's Name
Please enter Student's First, MI, Last Name
Phone Number *
Phone Number
Please choose program of your interest.
Proposed Start Date *
Proposed Start Date
Please enter a date when you would like to start classes.
Student Date of Birth *
Student Date of Birth
Parent's Name (If Applicable)
Parent's Name (If Applicable)
Please enter Parent's name if child is under 18 years old.
Credit Card will not be charged until a confirmation date/time is arranged with the parents/students.
Please enter credit/debit card number below.
Expiration Date *
Expiration Date
Please enter the 3 or 4 numbers in the back of the card.
Please enter the Billing Zip Code where you receive the statements.
Electronic Signature *
Electronic Signature
By signing this, I agree to all Rhythm & Pitch Policies and Procedures/Liabilities.
Checkbox *
By check this box I agree to Rhythm & Pitch Policies and Standard Operating procedures.