Afterschool Music Business Program Registration Form
Student Information
Student's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade
*
School
*
Will you be needing transportation?
*
Please Select
Yes
No
If YES, please provide pick up location
*
put N/A if No
Payment Method?
*
Please Select
Self-Pay
Step up for Students Scholarship
Other
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship to Student
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about our program?
*
Please Select
Returning Student
Referral from a friend
Social Media Marketing
Internet Search
If referral, please let us know who we should thank.
If Referral, who should we thank?
Fill in their name in the space above.
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.
Parent/Guardian Name
*
First Name
Last Name
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Relationship
*
Medical Information
Parents/guardians must accurately disclose any pertinent medical information about their child, including allergies, existing medical conditions, and current medications.
Allergies
*
Medications
*
Medical Conditions
*
Primary Physician Name
*
First Name
Last Name
Physician Phone Number
*
Please enter a valid phone number.
During our after school program, staff members will not administer medication but will provide basic first aid as needed. 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
Permissions
Field Trip Permission: I give permission for my child to participate in all scheduled field trips. I understand that extra precautions will be taken to ensure the safety of my child.
*
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
IMB has partnered with Life Center Village to provide wraparound youth services. By participating in our program, you will have access to a variety of resources aimed at supporting youth development. These resources include, but are not limited to, youth mentoring, mental health counseling, tutoring, and other enrichment activities designed to enhance personal and educational growth. A Life Center Village representative will contact you to assess your needs.
*
Please Select
I Agree
Date Signed
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: