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Refunds available until three days prior to your first lesson Student InformationStudent Name* First Last Date of Birth* MM slash DD slash YYYY Age*GenderSelect...FemaleMaleOtherEthnic CategoryFor analysis purposes only.Select...American Indian or Alaskan Native (Not Hispanic or Latino)Asian (Not Hispanic or Latino)Black or African American (Not Hispanic or Latino)Hispanic or LatinoMultiracial/Two or More Races (Not Hispanic or Latino)Native Hawaiian or Pacific Islander (Not Hispanic or Latino)White (Not Hispanic or Latino)PhoneEmail* Enter Email Confirm Email School*If not in school, please enter None Parent InformationParent/Guardian Name First Last PhoneEmail Enter Email Confirm Email Lesson InformationSeriesStudio SeriesProfessional SeriesLessons - Studio Series*Select...TrumpetMellophoneFrench HornTromboneBaritoneEuphoniumTubaFluteClarinetSaxophoneColor GuardField ConductingLessons - Professional SeriesDrum SetFluteFrench HornPacific Crest will match you with one of our private instructors; however, if you wish to request a specific instructor, you may enter their name in the next field. We will do our best to accommodate you.Instructor Requested (optional) Instructor - Professional SeriesMarvin "Smitty" SmithShannon CancholaBeckie EusonPromotional Code Lesson Type - Studio Series*Select...45-Minute Lesson (1 Lesson) - $5045-Minute Lesson (4-Pack) - $180Lesson Type - Professional Series*Select...45-Minute Lesson (1 Lesson) - $7045-Minute Lesson (6-Pack) - $42045-Minute Lesson (12-Pack) - $7801-Hour Lesson (1 Lesson) - $851-Hour Lesson (6-Pack) - $5101-Hour Lesson (12-Pack) - $960Lesson Type - Grant Funded*Select...30-Minute Lesson (1 Lesson) - $3030-Minute Lesson (6-Pack) - $15030-Minute Lesson (12-Pack) - $28845-Minute Lesson (1 Lesson) - $4045-Minute Lesson (6-Pack) - $21045-Minute Lesson (12-Pack) - $396Private Lesson TermsSchedule* I/We agreeLessons must run on schedule in order to not interrupt the flow of other lessons scheduled with the same teacher. Missed Lessons* I/We agreeMissed lessons may be made up at another time, but no refunds will be granted. Instructor Assignment* I/We AgreePacific Crest reserves the right to reassign a private music lesson student to a different instructor if necessary. Cancelled Lessons* I/We AgreeIf the lesson cannot start on time, it will not be cancelled for a period of up to the first 10 minutes. If the lesson does not commence within the first 10 minutes, all parties agree to treat the tardy as a missed lesson and agree to arrange a make-up lesson.Student Signature* Enter full name.Parent Signature* Enter full name.Signature* I/We AcceptI/We understand that checking this box constitutes a legal signature confirming that I/we acknowledge and agree to the above terms of the Pacific Crest Private Lessons Program.PaymentTotal $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If paying by credit card, this address must match the billing address for your credit card.Cardholder Email* Enter Email Confirm Email CAPTCHACredit card approval requires that the billing address, including Zip code, match the information on your credit card billing statement.NameThis field is for validation purposes and should be left unchanged.