Registration Form

Please fill in this form and submit it by clicking the button at the end. (The fields marked with a red asterisk are required.) You can expect to hear back from me within 48 hours.

I look forward to working with you!

Part A: Please fill in your personal information

Full name: *

Name you'd like me to use at your lessons:

Birthdate:

Home address:

Email address: *

May I send you the next issue of my email newsletter?:

Yes

No

(You will be given a choice of receiving further newsletters or unsubscribing.)

Phone number(s): *

Occupation:

Part B: Please list someone to call in case of emergency

Name:

This person's relationship to you:

Phone number(s):

Part C: How did you hear about me?

Source:

From someone you know. Please tell me who it was.

From a web search. Please list the search engine and phrase you searched on.

From a link on another website. Which site?

Other (please explain).

Source detail:

Part D: Please indicate the type of lessons you wish to take

Types:

Voice lessons (skip to Part G)

Alexander Technique lessons or programs (continue with Part E)

Both (continue with Part E)

Part F

Please read the following medical disclaimer, then type in your full name, which constitutes your online signature.

The Alexander Technique is an educational process and not a form of diagnosis or treatment or healing. Some conditions may require medical or other healing intervention. You must inform Michael of any relevant changes in your medical status, including episodes of pain or discomfort, that arise while studying with Michael.

Signature (Enter your full name): *

Date: *

Part G

Please read my policy on lateness, cancellations, and payments, then type in your full name, which constitutes your online signature.

You must arrive on time for lessons and may be required to pay the full fee for any lesson shortened by your late arrival. Since there is no waiting area in Michael's teaching studio, you may be requested to wait downstairs in the main lobby of the building until your lesson time if you arrive more than 5 minutes early.

You must give at least 12 hours’ notice to cancel a lesson. Unless there are extenuating circumstances (to be determined by Michael), you may be required to pay in full for any lesson cancelled without sufficient notice. (All students are granted one free waiver of this policy every six months to accommodate occasional emergencies.)

Each lesson must be paid in full no later than at the conclusion of that lesson by cash or check or before the lesson by credit/debit card through Paypal. If a check you write is returned unpaid by your bank, Michael will assess a $15 processing fee and may elect to require payment by cash or credit/debit card in the future.

Signature (Enter your full name): *

Date: *