STUDENT NAME

COST OF LESSON

PRIVATE TEACHER SIGNATURE

PARENT SIGNATURE

DATE OF LESSON

Signature of Bluffton School Music Director authorizing payment ________________________________________________________

Signature of Bluffton Music Booster Treasurer confirming payment _______________________________________________________

Signature of Student confirming payment received ____________________________________________________________________

Check made out to (filled in by parent/guardian) _____________________________________________________________________

Booster check number ___________________ Date of issued check _____________________ Amount $______________________