Music STEMS

Music Stems

by Youth Tech Success Inc
Participants Full Name
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Grade Level*
Parent / Guardian Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Person
Name*

First NameLast Name
Relationship to Participant*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Does the Participant have any medical issues? if Yes please list below.*
Medical Issues*
Does the Participant take any medications? If Yes please list below.*
Medications Used*
Consents
I hereby grant permission for photographs, videos, and audio recordings of the participant to be used by Music STEMS / Youth Tech Success Inc. for promotional purposes, including but not limited to website, social media, and marketing materials.*
I, the undersigned parent or legal guardian of the participant, acknowledge that I have read and understood the Music STEMS Youth Program Registration Form. I consent to the participation of my child in the program and agree to the terms and conditions outlined.*
Please verify that you are human*
Should be Empty:

Participants Full Name