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Please fill out this form to enroll in our auto bill pay which will be on the 1st of each month.

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

First Responsible Party Name

First Name*

Last Name*

Phone*
First Responsible Party Date of Birth*
I certify that I am 18 years of age or older
First Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
First Responsible Party Signature*
Second Responsible Party Name

First Name*

Last Name*
Second Responsible Party Date of Birth*
Second Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Third Responsible Party Name

First Name*

Last Name*
Third Responsible Party Date of Birth*
Third Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Fourth Responsible Party Name

First Name*

Last Name*
Fourth Responsible Party Date of Birth*
Fourth Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Fifth Responsible Party Name

First Name*

Last Name*
Fifth Responsible Party Date of Birth*
Fifth Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Sixth Responsible Party Name

First Name*

Last Name*
Sixth Responsible Party Date of Birth*
Sixth Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Seventh Responsible Party Name

First Name*

Last Name*
Seventh Responsible Party Date of Birth*
Seventh Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Eighth Responsible Party Name

First Name*

Last Name*
Eighth Responsible Party Date of Birth*
Eighth Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Ninth Responsible Party Name

First Name*

Last Name*
Ninth Responsible Party Date of Birth*
Ninth Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Tenth Responsible Party Name

First Name*

Last Name*
Tenth Responsible Party Date of Birth*
Tenth Responsible Party Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Responsible Party Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Select Card Type *
Visa
Mastercard
American Express
Discover

Card Number *

Expiration Date *

CVC Code *

Billing Zip Code *
I authorize Cal Heights Music to charge my credit card above for tuition(s) and fees related to enrollment and registrations. I understand that my credit card will be saved to file for future transactions on my account. *
I agree
Please enroll me in auto bill pay. Credit card on file will be charged on the 1st of the month.*
Yes
No
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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