Student Application
This is the general application to join The Roots of Music (ROM). Please only submit one application per student. You must complete a new form for siblings and multiple applicants. The requirements for admission are as follows: -Students must live/attend school in Orleans Parish. -Students must qualify for free or reduced school lunch. -Students must be aged 9-14 years.
Student Name
*
First Name
Middle Name
Last Name
Student Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Student's Gender's
*
Male
Female
Date Of Birth
*
-
Month
-
Day
Year
Date
Student Ethnicity
Please Select
Black/ African American
Native American
Caucasian
Native American
Hispanic/ Latin American
Other
Student Phone Number
Please enter a valid phone number.
Student Grade Level
*
Please Select
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
***At the time of Application
School Attending
*
School Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
School Released Time
*
Hour Minutes
AM
PM
AM/PM Option
Student T-Shirt Size
*
Please Select
Youth Small
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #1 Email
*
example@example.com
Parent/ Guardian #1 Phone Number
*
Please enter a valid phone number.
Parent/ Guardian #2 Name
First Name
Last Name
Parent/ Guardian #2 Email
example@example.com
Parent/ Guardian #2 Phone Number
Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Relationship to Student
*
Please list any known medical conditions or ailments to consider regarding the applicant. If there are none to list, please type "N/A"*All ROM students are subject to physical activities that range from moderate to strenuous. We must be aware of any medical conditions or ailments that may require exclusion from certain activities.
*
Does the applicant have any dietary restrictions?
*
Please Select
No Food Restrictions
Vegetarian
Vegan
Gluten-Free
Food Allergies
Which instrument does the applicant wish to learn? Chose TWO sections*Based on availability. ROM instructors reserve the right to place students where deemed appropriate.
*
Upper Brass (Trumpet, Mellophone)
Lower Brass (Trombone, Baritone Horn, Sousaphone/Tuba)
Woodwind (Clarinet, Saxophone, Flute)
The Roots of Music Inc. offers daily bus transportation at no cost to you. Please check any/all boxes that apply.Bus service is provided by a trusted third party contractor. Service may be limited to certain areas. Some restrictions may apply.
*
This applicant requires bus service from his/her school to ROM during weekday programming (Mon-Thu).
This applicant requires bus service from ROM to Home during weekday programming (Mon-Thu).
This applicant requires bus service to and from ROM on the weekend (Sat).
I will NOT require bus service for the applicant.
By submitting this application, the applicant is not guaranteed a spot in The Roots of Music. Once applications are submitted, they are reviewed by our staff. Parents/Guardians will be notified by a ROM representative, and given a date when the applicant may start attending the program. There will be documents for the parent/guardian to sign and return before the applicant is allowed to fully participate.
*
"I have read the above text and agree."
Submit
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