The Mobile Music Teachers LLC policies for temporary withdrawal from lessons are as follows:
Student's Name
Guardian's Name
Home Phone
Cell Phone
Work Phone
Email
Current Address
City, State
Zip Code
Teacher's Name
Instrument Being Taught
Please check the month(s) when lessons will NOT be received JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
I will resume lessons the month of ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Compliments (Optional)
Concerns (Optional)
I have read and understand the Vacation policies above. I hereby authorize the temporary withdrawal of the student(s) from their lessons with Mobile Music Teachers LLC. By typing my name below, I authorize the verification of the information provided on this form as correct.
Signature of Student (or Guardian if student is under 18)
Date (mm/dd/yyyy)