Hillary T. Dumond

Violinist, Violist, Instructor

Registration Form

Please print out and bring to your first lesson:



Student's Name:__________________________________________ Date of Birth: ___________________

Street Address:______________________________________ City, State & Zip:_____________________

Parent's Name (for billing purposes):________________________________________

Home Phone:____________________ Cell Phone:____________________  


Previous Musical Experience:_______________ Any Medical Alerts?_______________


Register for Private Lessons in:  Violin:____ Viola:____

Length of Lesson: 30 min____ 45 min____ 1 hour____

Tuition: $25 per 30 min, $35 per 45 min, $50 per hour.


Payment: Lessons will be billed on a monthly basis and tuition is due at the first lesson of each month.  Please make checks payable to Hillary Tanaka.  Tuition not paid within the current month will be assessed a  $10 late fee. There is a $20 fee for any returned checks.

Release of Liability:  I understand that my participation or that of my child, in the activities at Hillary Tanaka's Violin Studio, is optional.  I assume all risk of injury for myself or my child(ren), and hereby waive any and all claims which may arise against Hillary Tanaka from any injury or ailment directly or indirectly related to me or my child(ren) participating in the activities of Hillary Tanaka's Violin Studio.  In the event of a medical emergency, every effort will be made to reach the parents immediately; if unable to reach you, this authorizes Hillary Tanaka to call 911.

Photo/Media Release: I hereby grant Hillary Tanaka's Violin Studio the right to use the name and image of the student in all forms and in all media manners, for marketing, advertising or other lawful purposes.          Yes____ No____


Your signature below denotes your understanding and acceptance of Hillary Tanaka's Violin Studio policies and all the above stated policies and conditions.

______________________________________________________       ___________________

Parent Signature                             Date