Student Name *

First Name

Last Name

Parent/Guardian Name (if applicable)

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent to Auto Draft Payments *

I hereby authorize Mike Hilbun to electronically withdraw the amount of my guitar lessons payment from my checking account automatically each month.

Image Use

I allow Mike Hilbun to use any photos taken during lessons to be used in printed and online publicity to for promotional purposes.