SACSPA-Private Lesson Registration

SACSPA Registration Form

Private Lessons

1. Parent Name(s):

2. Email address:

3. (a.)Home Phone:

(b.)Work Phone:

(c.)Cell Phone:

4. Student Name:

5. Please select the private lesson:

6. Emergency Contact:

(a.)Name:

(b.)Phone:

(c.)Relationship:

7. Medical Information:

(a.) Does your child have any allergies? Medications?

(b.) If yes, please explain:

(c.) Doctor's name:

(d.) Phone:

(e.) Does your child have any physical problems or limitations?

(f.) If you checked "yes" above, please describe:

8. Please select your payment method:

15 minute lesson (recommended for 3 - 4 year olds) = $15

20 minute lesson = $20

30 minute lesson = $30

45 minute lesson = $40

60 minute lesson = $50

To pay by PayPal, please select one of the buttons below:

To pay by check or money order, please make payable to SACSPA and mail to:

St. Augustine Community School of Performing Arts

214 San Marco Avenue

St. Augustine, FL 32084