New Student Registration

Child's Name / Nombre y Apellido de su hijo/a / Non timoun nan*

First NameLast Name

Child's Date of birth (MM/DD/YYYY) / Fecha de Nacimiento / Dat nesans timoun nan*

Child's T Shirt Size / Talla de camisa / Gwosè mayo timoun nan*

Does your child have a Musical Instrument? / ¿Tiene su hijo/a un instrumento musical? / Èske pitit ou a gen yon enstriman mizik?*

Is your child a returning student to our program? / ¿Es su hijo/a un estudiante que regresa a nuestro programa? / Èske pitit ou a se yon elèv ki retounen nan pwogram nou an?*

YesNo

Grade attending in Fall 2024 / Grado en el año escolar Fall 2024 / Klas ale nan otòn 2024*

School/Center child will attend in Fall 2024 / Escuela para el año escolar Fall 2024 / Timoun lekòl la ap patisipe nan sezon otòn 2024*

Center child will attend Volta After school program / Centro en el que asistirá al Volta After school program / Sant kote timoun ap patisipe nan pwogram apre lekòl Volta*

Is your child interested in private music instruction? / ¿Está su hijo/a interesado/a en clases de música privadas? / Èske pitit ou a enterese nan ansèyman mizik prive?

YesNo

Parent's Name and Phone Number / Nombre de padre y número de teléfono / Non Paran ak Nimewo Telefòn*

Parent's Name / Nombre del padre/madre / Non paran an*

First NameLast Name

Parent's Phone Number / Número de teléfono / Nimewo Telefòn Paran an*

Please enter a valid phone number.

Email address / Correo Electrónico / Adrès imel*

example@example.com

Emergency Contact Name and Phone Number / Contacto de emergencia y número / Non kontak ijans ak nimewo telefòn*

Emergency Contact Name / Contacto de Emergencia / Non kontak ijans*

First NameLast Name

Emergency Contact Phone Number / Número de teléfono de contacto de emergencia / Nimewo Telefòn Kontak Ijans*

Please enter a valid phone number.

Complete Mailing Address (for welcome package, communications, student prizes, etc.) / Dirección de envío (para pack de bienvenida, comunicaciones, premios, etc.) / Ranpli adrès postal (pou pake akeyi, kominikasyon, prim elèv, elatriye)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your child’s ethnicity? / ¿Cúal es la etnia de su hijo/a? / Ki etnisite pitit ou a?*

Have you and/or a parent or spouse served in the U.S. Military? (Check all that apply) / ¿Usted y/o sus padres o cónyuge han servido en las Fuerzas Armadas de los EE. UU.? (Marque todo lo que corresponda) / Eske oumenm ak/oswa yon paran oswa konjwen te sèvi nan militè ameriken an? (Tcheke tout sa ki aplike)*

SelfParent/SpouseNeither

Has your child been diagnosed with any of the following? / ¿Ha recibido su hijo/a alguno de los siguientes diagnósticos? / Èske pitit ou a te dyagnostike ak nenpòt nan bagay sa yo?*

Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (ADD, ADHD)Autist, Pervasive Developmental Disorder (PDD) or Asperger'sLearning DisorderPost-Traumatic Stress Disorder (PTSD)None of the abovePrefer not to answerOther

Has your child used special education support? Including Hearing Impaired, Emotionally impaired, Learning Disabled, and Cognitive Impaired / ¿Ha utilizado su hijo/a algún tipo de apoyo educativo especial? Incluyendo trastornos auditivos, emocionales, del aprendizaje o cognitivos / Èske pitit ou a te itilize sipò edikasyon espesyal? Sa enkli moun ki gen pwoblèm pou tande, ki gen pwoblèm emosyonèl, kigen andikap pou aprann, ak ki gen pwoblèm kognitif*

YesNoPrefer not to answer

Questions, comments, concerns (Any details we should know about your child that may affect their participation in the After-school Program)/ Preguntas, comentarios, etc. (Detalles que necesitamos saber de su hijo/a) / Kesyon, kòmantè, enkyetid (Nenpòt detay nou ta dwe konnen sou pitit ou a ki ka afekte patisipasyon yo nan Pwogram apre lekòl la)*

Preferred form(s) of communication / Método preferido de comunicación / Fòm kominikasyon pi pito*

PhoneE-mailTextDirect Mail

Legalities- 2024-2025 Volta Music Foundation After-school Program. Read the attachment and type your name as your legal signature for the Waiver of Liability and Hold Harmless Agreement (Sign and date below) / Lea el archivo adjunto y escriba su nombre como su firma legal para el Acuerdo de exención (Firme y coloque la fecha a continuación) / Legalite- 2024-2025 Volta Music Foundation Pwogram apre lekòl. Li atachman an epi tape non w kòm siyati legal ou pou Akò Egzanpsyon Responsablite ak Kenbe Inonsan (Siyen ak dat anba a)*

Date

In consideration of my being allowed to participate in the 2024-2025 Volta Music Foundation Afterschool Program conducted by VOLTA MUSIC FOUNDATION, Inc. from on or about September, 2024 to May, 2025; I the undersigned, to the fullest extent permitted by law, hereby voluntarily release, discharge, waive and relinquish any and all actions or causes of action for personal injury or property damage, occurring to me as a result of my participation in the AFTERSCHOOL PROGRAM and/or any activities incidental thereto wherever or however the same may occur. To the fullest extent permitted by law, I, for myself, my heirs, executors, administrators, and assigns hereby release, waive, discharge, and relinquish any action or causes of action, aforesaid, which may hereafter arise for me and/or for my estate, and agree that under no circumstances will I or my heirs, executors, administrators, and assigns prosecute, present any claim for personal injury, property damage or wrongful death against VOLTA MUSIC FOUNDATION, INC., its facilities, or any of its trustees, officers, instructors, employees or agents (RELEASEES), for any of said causes of action, whether the same shall arise by the negligence of any said persons, fellow participants, teachers, students, independent contractors and others including those participating in the AFTERSCHOOL PROGRAM. IT IS MY INTENTION BY THIS INSTRUMENT TO EXEMPT AND RELIEVE VOLTA MUSIC FOUNDATION, INC. FROM LIABILITY FOR PERSONAL INJURY AND PROPERTY DAMAGE. I further hereby agree to indemnify and hold harmless RELEASES, to the fullest extent permitted by law, from any loss, liability, damage and costs including court costs and attorneys’ fees, that they may incur due to my participation in the AFTERSCHOOL PROGRAM, whether caused by negligence of RELEASEES or otherwise. I have no physical condition that would prevent me from participating in this event. I am in good health and physical condition. I am fully aware that there are risks and hazards, known and unknown, connected with the AFTERSCHOOL PROGRAM, and I voluntarily assume those risks and hazards connected with the AFTERSCHOOL PROGRAM. I understand that I am responsible for obtaining treatment for any injuries sustained while participating in the AFTERSCHOOL PROGRAM. I represent that I do not have nor have I tested positive for the COVID 19 virus. I further represent that I have not been exposed to any persons who have tested positive or exhibit symptoms for the COVID 19 virus at any time during the 7 daytime period prior to the start of the Afterschool Program. I understand that should I be exposed to a person with the COVID 19 virus at any time during the duration of the Afterschool Program, I have the affirmative obligation to notify VOLTA MUSIC FOUNDATION INC. as soon as possible. Any doubts should be resolved in favor of notifying VOLTA MUSIC FOUNDATION INC. I give my full permission to VOLTA MUSIC FOUNDATION, INC. to use any photographs, video, audio or other recordings of me that are made during the course of this Program. I understand that I will have no ownership interest or copyright interest in any photographs, videos, audio or other recordings that are made during the course of this Program. I expressly acknowledge that this RELEASE is intended to be as broad and inclusive as permitted by the laws of the State of Florida, and that this RELEASE shall be governed by and interpreted in accordance with the laws of the State of Florida, and venue for any legal proceeding or lawsuit shall be in Broward County, Florida. I agree that in the event that any clause or provision of this RELEASE shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this RELEASE which shall continue to be enforceable. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I HAVE READ IT IN ITS ENTIRETY, UNDERSTAND IT AND VOLUNTARILY SIGN IT AS MY OWN FREE ACT AND DEED; THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENTS NOT CONTAINED HEREIN HAVE BEEN MADE TO ME BY ANY OF THE RELEASES; THAT I AM AT LEAST EIGHTEEN (18) YEARS OF AGE AND FULLY COMPETENT; OR THE PARENT/GUARDIAN OF THE PERSON PARTICIPATING IN THE AFTERSCHOOL PROGRAM; AND THAT I EXECUTE THIS RELEASE FULLY INTENDING TO BE BOUND BY SAME.

Sign with your name below / Firme con su nombre a continuación / Siyen ak non w anba a*