Summer Camp Registration

Student Information

First Name*

Last Name*

Birthdate*

Gender*

Medical Condition / Allergies*

Yes

Please list*

Are you registering more than one child for music lessons?*

Yes

Please enter the names of the children

You will need to fill out a SEPARATE registration form for each child. A 10% discount will be applied to the total family tuition for 3 or more students registering together.

Camp Information

Camps*

Camp Days*

Camp Fees*

Contact Information

Name*

Email Address*

Primary Phone Number*

Alternate Phone Number

Contact Name of Alternate Phone Number

Street Address*

Unit Number

City*

Postal Code*

Finance Information

Are you a new customer to MSI Langley?*

Yes

Banking Information*

Use same as on file

New/update financial information

Bank Account Holder's Name*

Institution Name*

Account Type*

Chequing

Savings

Institution Number*

Branch Number*

Account Number*

Attach a PDF/JPEG of VOID Cheque

Accepted file types: pdf, jpg, jpeg, Max. file size: 5 MB.

Is the mailing address of the bank account holder different from the contact information you entered above?*

Yes

Account Holder's Name*

Mailing Address*

Primary Phone Number*

Email*

Terms

Camp Payment

Pianorama Camp fees are due upon registration. Fees are non-refundable, however if a student is sick or unable to attend the camp we will do our best to find another student to take their spot. If we are able to fill the spot, we will issue a refund. If we are unable to fill the spot a refund is not guaranteed.

Authorization

I / We authorize Music Schools International Langley to withdraw from the financial information indicated (above) for the full payment of the Pianorama Summer Camp on the day of registration. I/We warrant and guarantee that the person(s) whose signature(s) are required to sing on the account have signed the authorization.

Reimbursement

• I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdypay.ca.

Camp Payment, Authorization and Reimbursement I agree*

I agree

E-Mail Communication Authorization

To receive important lesson, news and event information via email from MSI Langley, we are required by law to obtain your consent. If you agree, please check below.

E-Mail Communiation Authorization I agree*

I agree

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