Memphis Youth Arts Program Enrollment Form

PROGRAM ENROLLMENT APPLICATION

MEMPHIS YOUTH ARTS INITIATIVE | MEMPHIS, TN
STUDENT INFORMATION
STUDENT NAME*

First NameLast Name
AGE*
Current School Attending*
GRADE For Upcoming or Current School Year*
Date of Birth

MonthDayYear
What is your student gender identity?*

MaleFemaleBinaryOther
Guardian / Parents Names*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone*
Parent E-mail*
example@example.com
Performing Arts Skill Level*

1

2

3

4

5

1 is Begginer, 5 is Advanced
Select Programming For Your Student to enroll? (Select all that apply)*

Mega Sounds BandLoud Pac DrumlineMentoring, Tutoring, & SELSmooth Groves Cover BandFree Music & Dance LessonsPrivate Lessons (Piano, Voice, Drum)Community Services RequirementWorkforce DevelopmentOther
Please share with us a little about your student and what your goals are for them joining this organization?
Select Instrument of Choice (For Music Programs Only, if selected above)

ClarinetSaxophoneFlute/PiccaloTrumpetBaritoneTromboneTubaMellophoneSnare DrumTenor DrumBass DrumCymbalsQuads/QuintPianoLead/Bass GuitarDrum SetMallet PercussionOther
Important Notes

· We can select an instrument for you if you are new to playing in a band.

· We have a limited inventory of instruments so renting or purchasing an instrument is always an option.

· Private Lessons must be scheduled and have a cost per 6 sessions. Deposit Required to start 1st Session. Please call (901) 677-9695 to have a consultation about private lessons.
Emergency Contact & Health Insurance Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Does your child have any allergies, chronic illness, or medical conditions that would limit high level activtiy?*

YesNo
Please describe
Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Name of Physician / Emergency Medical Care Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Release of Liability

Although the safety of all activities is the primary concern, any activities at MYAI Center/Southland Mall facilities may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against the Memphis Youth Arts Initiative/Southland Mall and the persons in charge.
I have read and agree to the above conditions*

YesNo
Confirmation E-mail*
example@example.com
Enrollment Fee for Memphis Youth Arts Initiative
prevnext( X )
Enrollment Fee for One StudentMonthly Dues Cost for 1 Student
$40.00 Quantity



MYAI T-ShirtIntroductory T-Shirt for all new Members! Wear it for your first performance.
$25.00 QuantitySize



FREE ENROLLMENT for MENTORING PROGRAM
$ Free Quantity



Total

$0.00
Signature*

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PROGRAM ENROLLMENT APPLICATION

Release of Liability