SoundPathways Program Application

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Student Name* This field is required.
First Name
Last Name
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Student Personal Email* This field is required.School email addresses may not be used.
example@example.com
Email Verified
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3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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High School Name* This field is required.
5
Parent/Guardian Name* This field is required.
First Name
Last Name
6
Parent Email* This field is required.
example@example.com
7
Parent Phone Number* This field is required.
Please enter a valid phone number.
8
Parent Consent & SignatureNOTICE OF RIGHTS UNDER HIPAA AND FERPA The Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) are federal laws that protect the privacy of your child's health information and education records, respectively. You have the following rights under these laws: HIPAA Rights The right to access and obtain a copy of your child's health information The right to request a correction to your child's health information The right to request that your child's health information be shared with certain individuals or entities The right to file a complaint with the U.S. Department of Health and Human Services if you believe your child's privacy rights have been violated FERPA Rights The right to inspect and review your child's education records The right to request that your child's education records be amended if they are inaccurate or misleading The right to consent to the disclosure of your child's education records, except in certain circumstances The right to file a complaint with the U.S. Department of Education if you believe your child's privacy rights have been violated Media Release I, give permission, to use my child's name, voice, image, and/or likeness in any and all forms of media, including but not limited to photographs, video recordings, audio recordings, and written content, for the purpose of promoting or publicizing the school or organization's programs and events. I understand that my child's name, voice, image, and/or likeness may be used in various media outlets, including but not limited to the school or organization's website, social media accounts, promotional materials, and news releases. I also understand that my child's name, voice, image, and/or likeness may be used by the school or organization after my child has graduated or left the school or organization. I acknowledge that my child will not receive any financial compensation for the use of their name, voice, image, and/or likeness. I hereby release and discharge the school or organization, its officers, agents, employees, and assigns from any and all claims, damages, or liabilities arising from or related to the use of my child's name, voice, image, and/or likeness. I certify that I am the parent or legal guardian of the child named below and have the legal capacity to sign this release. Communication Consent By checking this box, I consent to receive text messages from the Ann Cephus Family Fund (ACFF) for both myself and my child(ren). These messages may include program updates, application status, event notifications, and other relevant information. I understand that message and data rates may apply. I also acknowledge that I have the authority to provide consent for my child(ren) to receive text messages. I can opt out at any time by replying "STOP" to any message.
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9
School Grade* This field is required.
9th Grade
10th Grade
11th Grade
12th Grade
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Please rate how exited are you to participate in one of our programs!* This field is required.
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