END OF SUMMER REMIX Enrollment Form

END OF SUMMER REMIX: Turn it up. Catch a vibe.

Wednesdays 3:00–5:00 PM • August 5 – Sept 23
Welcome to the END OF SUMMER REMIX Session! 🥳🎶🎸

Mentoring with Music is where passion turns into power. Founded by visionary Jason S. Henderson, our program is built to ignite Lima’s youth through the unstoppable force of music. For eight high‑energy weeks, young creators ages 8–18 jump into music production at SUNE Records, 1176 W. North St., Lima, OH 45805 — the same studio where local artists make magic happen. Your child won’t just learn music — they’ll live it. Songwriting. Vocal recording. Beat‑making. Mixing and mastering. Stage performance. Every session is hands‑on, and guided by seasoned music pros who know how to bring out your child’s confidence, creativity, and voice. They’ll build skills, make friends, and step into a community that celebrates who they are and who they’re becoming. We’re fired up to launch our END OF SUMMER REMIX session with you! Classes are FREE and we never turn a child away. Questions? Call or Text Liz Whitney at 614‑285‑2777 or Jason Henderson at 419‑236‑6782. You can also email us at liz.whitney@mentoringwithmusic.org or jason.henderson@mentoring.org. Let’s close summer on a high note! 🥳🎶🔥🎤🥁🎸
Student Information
Student Name

First NameLast Name
Student Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Gender Assigned at Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Email Address
example@example.com
Experience and Goals
Previous Music Experience
Goals for Creative Development
Parent/Guardian Information
Parent/Guardian Name (if student is under 18)

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Student
OhioRISE Students

(We Accept Flex Funds!)
Name

First NameLast Name
Is your child enrolled in OhioRISE?
OhioRISE / Flex Funds ID Number
Care Coordinator Information

First NameLast Name
Care Coordinater’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Care Coordinator’s Email
example@example.com
Sponsorship Option

*FREE Classes for Families on Medicaid or SNAP.
FAMILY ON MEDICAID: Please upload your Medicaid/SNAP card (front and back) and a valid state-issued photo ID.

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FIXED OR LOW INCOME: Working but DO NOT qualify for Medicaid—Upload your last three paystubs for proof of income, and a valid state-issued photo ID.

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Program Fees for Working Families

Families who do not qualify for our sponsorship option may participate at a standard rate of $15 per week for the eight‑week session. This fee supports instruction, materials, and the food, snacks, and beverages provided during class. Families may choose to pay weekly through automatic debit‑card withdrawal, or pay the full session amount in advance at a discounted rate of $10 per week ($80 total). If your family is experiencing financial difficulty, you may select the sponsorship request option on this form or contact Liz directly at 614-285-2777 to discuss a private arrangement.

USD

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Terms and Conditions:

As the parent or legal guardian, I give permission for my child to participate in the Mentoring with Music program, held at SUNE Records (1176 W. North St., Lima, OH 45805). I understand and agree to the program guidelines. If my child needs to miss a class, I will send a written cancellation to Liz Whitney at liz.whitney@mentoringwithmusic.org at least 24 hours in advance. I understand that missing this deadline may result in my child's temporary suspension from class.
Parental Media Release for Minor

By registering your child for this eight‑week Mentoring with Music session, you, as parent or legal guardian, grant Mentoring with Music and its partners permission to photograph and record your child during classes, special events, and field trips. You consent to the use of these images, audio, and video for promotional, educational, and documentation purposes in any media (including print, website, and social media), without compensation, and you understand they may be edited for length or clarity. Mentoring with Music will use your child’s likeness respectfully and may discontinue future use upon written request, though this will not affect materials already produced or published.
Student/Parent/Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

END OF SUMMER REMIX: Turn it up. Catch a vibe.

Welcome to the END OF SUMMER REMIX Session! 🥳🎶🎸

Student Information

Experience and Goals

Parent/Guardian Information

Emergency Contact Information

OhioRISE Students

Sponsorship Option

Program Fees for Working Families