Beats Of Transformation Summer Enrichment Enrollment
Student Information
Name
First Name
Last Name
Grade
School Last Attended
Gender
Please Select
Male
Female
N/A
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first
*
Emergency Information
Name
First Name
Last Name
Relationship
Phone Number
Format: (000) 000-0000.
Health Information
Family Doctor
First Name
Last Name
Clinic
Name and Address
Phone Number
Format: (000) 000-0000.
Please let us know if this child have any allergies
*
List medications if this child is currently taking
*
Have this child had any serious illnesses or operations?
Yes
No
If yes, please describe
Do you want to indicate any related information?
Permissions
Please check each box to indicate your consent:
Rows
I consent
I do not consent
I grant permission for my child to participate in all Beats of Transformation summer program activities.
I grant permission for my child to be photographed or recorded for program promotional purposes.
I authorize Inspire Music Collective staff to seek emergency medical treatment if necessary.
I understand the program runs Friday, June 14-Aug 16 and I will ensure my child attends regularly.
Date of Registration
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: