Lippert Online Registration Form


* indicates required field
  • Male Female


  • NewReturning    Years of experience:  
  • OwnRent
  • OwnRent
  • OwnRent
  • Beginner      Book(s) & Level:  
  • RCM Grade:              RCM#:    Other:  
  • Beginner Basic Intermediate Advanced Other
  • Group Ensemble Stage Acting
  • Dance School of Hard Rock
  • 30 min. 45 min. 60 min.
  • Yes No
  • Yes No
Yes No


  • Current School:
      Grade:   Date of Birth - Day: Month: Year:
Primary Contact
  • Info same as applicant
Secondary Contact
  • Info same as applicant
Yes No


Please indicate any allergies, conditions and health concerns:

  • 1 2 3 4
  • Before and after hours care request (Extra Fee's Apply)
  • I agree all missed lessons are charged, regardless of notice.
  • I agree to pay for lessons before the first of the month, and I will pay a $10.00 late fee for lesson payments arriving late.
  • I agree that there are no refunds once a month has started.
  • Make-up Lesson Policy: If I have paid by Options #1 or #2, I agree to one make-up lesson per school year for the student and one for the teacher, at the studio's convenience. I have read, understand and agree with all policies outlined in the MAKE-UP LESSONS section of the School Policies. I understand that there are NO make-up lessons for Option #3 or if I am starting after Term 1. I understand if I miss my agreed upon make-up time, I forfeit my make-up.
  • If lessons are discontinued, I agree to give 7 days notice prior to the end of the month or I may be charged for an extra lesson(s). Cheques/fees for Options #1 or #2 will be returned for unused lessons less all applicable discounts.
  • I agree to pay a $30 service charge for any NSF cheques.
  • I understand that fees and unused credit cannot be carried forward to the summer session or the next school year.
  • If I am a "Lippert on the Go" Student, I have read and agree to the make-up policy outlined in the School Policies.
* I agree to the Lesson Agreement

  • I agree that all missed lessons are charged and there are no make-up lessons for missed group classes regardless of notice.
  • I agree that there are no refunds 2 weeks prior to the start of the course.
  • I will pay in full for the class 2 weeks before the start date, in order to secure my spot. A $10.00 late fee for payments arriving after the start date may apply.
  • I agree to pay a $30 charge for any NSF cheques.
  • I understand and agree that any behaviour that limits the safety and enjoyment of other participants in a class or destroys equipment is not permitted. Should such a situation arise, participant may be removed upon a 2nd occurrence. I understand that I will be liable to pay for any damages that may occur.
  • For all theory courses, the student agrees to complete all assigned work on time. The student understands that not completing assignments may greatly affect the results of the examination at the end of the session.
  • I have consulted the website regarding policies and understand the policies and agree that there will be no refund of fees.
* I agree to the Group Lesson and Camp Agreement

Video Release Statement

I give my permission for my child to be photographed or video-taped during the course of the program. These photographs/videotapes may be used in promotional material for Lippert Music Centre Inc. Names and any other personal information will NOT be included with any Lippert Music Centre Inc. promotional material. No compensation will be given for any images taken.
I agree to the Video Release Statement

Release Statement

"I hereby release and waive any claims which I, my child and ward have now or may have in the future against Lippert Music Centre Inc. and its servants, staff and employees from any and all liability for any loss, damage, expense or injury and arising in negligence or otherwise, howsoever caused, and which relate to the participation of my child or ward in any lessons, program(s), camp(s) or classes. This release is binding upon my child or ward and upon their and my heirs executors and administrators, and I warrant that I have authority to enter into this release agreement on behalf of such child or ward."
* I agree to the Release Statement