We recommend that you use Safari or Chrome for this form. Users have reported issues with other internet browsers. Refunds available until three days prior to your first lesson Student InformationStudent Name* First Last Date of Birth* Date Format: 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)Phone*Email* Enter Email Confirm Email School*If not in school, please enter NoneParent InformationParent/Guardian Name First Last PhoneEmail Enter Email Confirm Email Lesson InformationLessons*Select...TrumpetMellophoneFrench HornTromboneBaritoneEuphoniumTubaSnare DrumTenorsMalletsColor GuardVisual - MarchingVisual - Dance/MovementField ConductingPacific 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)Promotional CodeLesson Type*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) - $396Lesson 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 ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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. This iframe contains the logic required to handle Ajax powered Gravity Forms.