2025 AFTERSCHOOL PROGRAM

Afterschool Enrollment Form

2025-2026 School term
PARTICIPANT INFORMATION
Participant's Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
If prefer to self describe please indicate below
Is the child/youth of Hispanic, Latino, or Spanish origin?*
Race (Please select one)*
What language(s) does the child/youth feel most comfortable speaking? (Select all that apply)*

EnglishSpanishOther
If "Other", please specify
Leave blank if not applicable
What will be the child/youth’s Fall 2025 grade level?*
What school will the Child/Youth's be attending Fall 2025?*
Student's ID# (if known)
Leave blank if unknown
HOUSEHOLD INFORMATION
Caregiver's Name*

First NameLast Name
Caregiver's Phone Number*
Please enter a valid phone number.
Is this a mobile phone?*
Caregiver's Email*
example@example.com
Realtionship to student*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Language Spoken at Home:*
If Other, please specify
Leave blank if not applicable
Number of Individuals in the Household? ______ *
Number of Children ages 0 - 17 in Household:*
Number of Children ages 18 - 24 living in Household:*
For your current housing, do you:*

OwnRentStay with friends or relativesLive in temporary shelterOther
Total Household Income*

$0 - $15,060$15,061 - $22,590$22,591 - $30,120$30,121 - $37,650$37,651 - $45,180$45,181 - $60,240More than $60,241
Which, if any, of the following do you or your family currently receive? (Check all that apply):*

Supplemental Nutrition Assistance Program (SNAP/food stamps)Social Security Disability Income (SSDI)MedicaidEarned Income Tax Credit (EITC)Temporary Assistance for Needy Families (TANF)Unemployment BenefitsState Health Insurance (including children’s healthinsurance)Supplemental Security Income (SSI)ELC/School ReadinessNone of the aboveOther
Do you need transportation to the Afterschool Program?*
If Yes, Please enter dismissal time.*
Type N/A if transportation is not needed
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 afterschool 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.*
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.*
Publishing Agreement: I agree to release publishing rights to IMB Music for educational and promotional uses for my contributions in this program without compensation*
Please be advised that during our afterschool 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. 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.*
Primary Physician's Name*
Physician's Phone Number*
Please enter a valid phone number.
List any allergies or medications*
Put N/A if none
Afterschool Enrichment Program Agreement This agreement outlines the program guidelines and responsibilities of both the parent(s)/guardian(s) and the IMB Afterschool Enrichment Program to ensure a successful and collaborative experience for all participants. Behavioral Expectations: Students are expected to engage respectfully with instructors, coaches, and peers. Attendance Policy: Consistent attendance is required to maximize program benefits. Please notify the program of absences in advance. Acknowledgment By signing this agreement, parent/guardian acknowledges their understanding and acceptance of the outlined guidelines and responsibilities.*
Caregiver's Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Signature*

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Afterschool Enrollment Form

PARTICIPANT INFORMATION

HOUSEHOLD INFORMATION