Contact Us

 

Please use the form on the right to contact us. Alternately, feel free to email us directly at info@midcoastmusicacademy.com or give us a call at  207-701-7401. Our studio is located at 279 Main Street in downtown Rockland, right next to Park Street Grille. We look forward to hearing from you!  

279 Main St
Rockland, ME, 04841
United States

207.701.7410

Student Registration

To register for private or group lessons at MCMA, please review the Student Policies, fill out the registration form below, and submit your first month's tuition payment to hold your slot. Thank you so much for joining MCMA, and we look forward to making music with you! 

Student Contact Information
Student’s Full Name *
Student’s Full Name
Student’s Preferred Name
Student’s Preferred Name
Student’s Best Phone Contact
Student’s Best Phone Contact
Student’s Mailing Address
Student’s Mailing Address
Student’s Music Information
Parent/Guardian Contact Information (if student is a minor)
Parent/Guardian Name 1
Parent/Guardian Name 1
Parent/Guardian 1 Phone Contact
Parent/Guardian 1 Phone Contact
Parent/Guardian Name 2
Parent/Guardian Name 2
Parent/Guardian 2 Phone Contact
Parent/Guardian 2 Phone Contact
Health Information
Emergency Contact Name
Emergency Contact Name
Primary Phone Contact
Primary Phone Contact
Secondary Phone Contact
Secondary Phone Contact
Physician’s Name
Physician’s Name
Physician Phone Contact
Physician Phone Contact
Student Policy Agreement and Waiver Release (must accompany Registration Form)
I am, an adult or the parent/legal guardian of the student, willingly enrolling in classes, lessons, and/or other related activities with Midcoast Music Academy. I have read the MCMA Policies and I clearly understand and agree to the MCMA payment and cancellation procedures within. By signing below, I acknowledge that I understand and agree to all policies, guidelines and conditions set forth above. Participation: I hereby consent and agree, for myself/my minor child, to participate in classes, lessons, rehearsals, performances and/or other related activities with Midcoast Music Academy (MCMA). I understand that I am fully responsible for myself/my child until such time that my/my child’s class, lesson, or other MCMA activity begins, and that I also am responsible for myself and/or my child immediately upon the conclusion of my/his/her activity at MCMA. This includes, but is not limited to, transportation to and from MCMA, all time spent waiting for the scheduled lesson to begin, and/or waiting for pick-up following a lesson. In consideration for MCMA accepting me/my child into its program, I do hereby for myself, my spouse, my children, our heirs, personal representatives and assigns, expressly release and forever discharge MCMA, its officers, agents, and employees of and from any liability and all claims, suits, or causes of action arising from or as a result of my/my child’s participation in MCMA programs, including, without limitation, injuries or damages sustained by myself and/or child on property managed by MCMA. Media: I hereby consent that photographs or videos taken of me/my child may be used for marketing purposes (only) on MCMA materials and/or website. I hereby assign full copyright to MCMA (and the related representatives and assigns) together with the right of reproduction either wholly or in part. I grant MCMA to, either separately or together, either wholly or in part, the perpetual and irrevocable and unrestricted right to use and publish video and/or photographs of me/my child, including any retouching or alteration. I understand that Students, if identified, will be identified on a first name basis only, that photographs or videos shall be deemed to represent MCMA, and statements or wording will not be attributed to me/my child unless directly quoted and referenced. I undertake not to prosecute or to institute proceedings, claims or demands against either MCMA or agents in respect of any usage of the above mentioned and release MCMA from all claims and liability relating to photographs or video taken. Emergency: In the event of an emergency, I hereby authorize and request MCMA to provide or secure me/my child to receive emergency treatment at a hospital and/or from a licensed physician should the need arise. I hereby give my consent for MCMA to seek necessary emergency medical treatment for me/my child, and for me/my child to receive such emergency medical treatment, which may be deemed necessary or advisable in the event of injury, accident or illness. I further understand that the emergency contact listed will be called immediately if any emergency arises and I accept financial responsibility for all such medical treatment that may be provided.
Electronic Signature
Electronic Signature
Date
Date