Enrollment forms

"School Without Walls"
Enrollment Form

I wish to order the School Without Walls "Jazz Keyboard " Course.

I have indicated the Lessons I am interested in receiving Below:

Jazz Keyboard Part1 (Retail $920.00)

Per Lesson (8 lessons total):

$110.00 Dollars per lesson

Complete in 1 Payment:

$828.00 Dollars Complete (10% discount)

Jazz Keyboard Part2 (Retail $600.00)

Per Lesson (5 lessons total):

$120.00 Dollars a month

Complete in 1 Payment:

$540.00 Dollars Complete (10% discount)

Jazz Keyboard Part1 & 2(Retail $1480.00)

Complete in 1 Payment:

$1184.00 Dollars Complete (20% discount)

_{* I understand that I am to make payments as detailed above.

My initial payment is the}_{amount shown above.}
_{* I understand that I can receive telephone/Email support as long as I need it.}
_{* I understand that I will receive a "School Without Walls"}
_{Certificate of Completion when I have successfully completed my current course.}
_{* All foreign students please pay in US Currency}

Below you will find the shipping and handling price schedules, be sure to use the schedule below to insert the correct shipping and handling price for your selected course in the space provided. "Other" on the schedule pertains to all countries other than the United States and Canada. A red "C" on the schedule means you must contact us by e-mail or phone for shipping and handling
prices for your area or region. dana@beyondchops.com (541) 552-9605

Course

Course Monthly

Course Complete

Course in 2 pymts

Course in 3 pymts

Your location

U.S.

CAN.

Other

U.S.

CAN.

Other

U.S.

CAN.

Other

U.S.

CAN.

Other

Jazz Keyboard 1

$12

N/A

$16

$20

$12

$14

$10

$12

Jazz Keyboard 2

$12

N/A

$20

$24

$14

$16

$10

$12

Jazz Keybrd 1-2

$30

$35

$24

$28

$16

$20

_{* I include payment in full.}
_{* All foreign students please pay in US Currency}

Course

Course Monthly

Course Complete

Course in 2 pymts

Course in 3 pymts

Your location

U.S.

CAN.

Other

U.S.

CAN.

Other

U.S.

CAN.

Other

U.S.

CAN.

Other

Beyond Chops

N/A

$20

$30

N/A

$15

$20

_{MAKE ALL CHECKS OR MONEY ORDERS PAYABLE TO: Dirk Price Music}
_{1237 Ashland Mine Road - Ashland, OR 97520}

Item Payment:

Check M.O. Cashiers Check.

Visa MasterCard

Shipping & Handling:

Discover

Total Enclosed:

Credit card or Check Number:
Expiration Date:

YOU MUST FILL OUT THE FOLLOWING ORDER INFORMATION

Name: Street Address:

City: State/Province: Zip/Postal Code:

Phone(home): Phone(work): Fax Number:

E-mail Address: Country:

Signature(if printing this form):

Instrument(s) you play:

Today's Date:

Optional Information:

_{Have you attended music school? (if so, name, how long, where?)}

_{If so, your major was:}

_{Have you received private lesson? (If so, what subject, how long, from whom?)}

_{Have you read any Dick Grove books? (if so, which books?)}

_{What other music instruction books have you studied?}

_{What/who are your musical influences?}

_{You short term goals?}

_{You long term goals?}

_{How did you hear about the School Without Walls?}

1-800-994-7683 or 541-552-9605
Click here to email us: Dana@BeyondChops.com

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