Participant Enrollment Form
PARTICIPANT INFORMATION
Participant's Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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2009
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
Transgender
Prefer to self-describe
If prefer to self describe please indicate below
Is the child/youth of Hispanic, Latino, or Spanish origin?
*
Please Select
Yes
No
Race (Please select one)
*
Please Select
American Indian or Alaskan
Asian
Black or African American
Pacific Islander
White
Biracial or Multiracial
Prefer to self-describe
What language(s) does the child/youth feel most comfortable speaking? (Select all that apply)
*
English
Spanish
Other
If "Other", please specify
Leave blank if not applicable
What is the child/youth’s current grade level?
*
Child/Youth's most recent school
*
Student's ID# (if known)
Leave blank if unknown
Student T-shirt Size
*
For Field Trips
HOUSEHOLD INFORMATION
Caregiver's Name
*
First Name
Last Name
Caregiver's Phone Number
*
Please enter a valid phone number.
Is this a mobile phone?
*
Please Select
Yes
No
Caregiver's Email
*
example@example.com
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Language Spoken at Home:
*
Please Select
English
Spanish
Creole
Mandarin
Arabic
Russian
Other
If Other, please specify
Leave blank if not applicable
Number of Children ages 0 - 17 in Household:
*
Number of Children ages 18 - 24 living in Household:
*
Please tell us anything you think it is important for us to know about you and your family’s needs to be happy and successful in this program (e.g., learning disabilities, special needs, other):
*
Please let us know if there are any scheduling conflicts that you might have during the summer program. *please include dates.
*
I give my permission for this information to be shared with the Institute of Music Business (IMB) and Children's Services Council of Leon County (CSC Leon), a funder of this program, I understand that my child will be asked to complete periodic surveys to measure program quality and impact. All information will remain confidential and participant names will never be associated with the data gathered.
*
Please Select
I Agree
Photography/Videography Release: I grant permission to use my photos and videos without payment; they may be published electronically, in print, or used in presentation/exhibitions.
*
Please Select
I Agree
Publishing Agreement: I agree to release publishing rights to IMB Music for educational and promotional uses for my contributions in this workshop without compensation
*
Please Select
I Agree
Please be advised that during our school summer program, staff members will not administer medication but will provide basic first aid as needed. It is important to note the following:Medical Information: It is imperative that parents/guardians accurately disclose any pertinent medical information about their child, including allergies, existing medical conditions, and current medications. This information will help us provide appropriate care in case of an emergency.Trained Staff: Our staff members are trained in basic first aid procedures and medication administration. However, they are not medical professionals. In serious medical situations, emergency services will be contacted immediately.Emergency Contact: Parents/guardians must provide up-to-date emergency contact information, including reachable phone numbers, in case we need to reach them regarding their child's health.Non-Liability: While we take every precaution to ensure the safety of all participants, Institute for Music Business and it's staff members will not be held liable for any unforeseen medical complications that may arise during the program.By enrolling you acknowledge and agree to the terms outlined above.
*
Please Select
I Agree
I give permission for my child to participate in summer program field trips. I understand that the institution will take reasonable precautions for the safety and well-being of the students during the trip.
*
Please Select
I Agree
Caregiver's Name
*
First Name
Last Name
Date Signed
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: