Fall Session 2025 Enrollment Form

Fall Session 2025 Enrollment Form

Orientation Day: Monday, 9/8 (3-7 PM) Classes: Tuesday, 9/9 - 10/28 (3-5 PM) (Serving Youth Ages 8-18)
Welcome! 🥳🎶

We are thrilled and grateful for your interest in Mentoring with Music. My name is Liz Whitney, the Executive Director of this extraordinary and innovative program. Our visionary President and Founder, Jason S. Henderson, had a dream of uplifting Lima’s youth and transforming their lives through the undeniable power of music. Jason and his team of seasoned music professionals employ a hands-on approach to impart the essential skills of various recording studio disciplines to young individuals. Through the enchanting world of music, we aspire to nurture your child’s creative and musical potential, fostering confidence and self-worth. Our mission is to ignite their imagination and pave the way for a brighter future. Should you have any questions, please don’t hesitate to contact me by phone at 614-285-2777 or via email at liz.whitney@mentoringwithmusic.org. Let’s create some beautiful music together! 🎼🎸🎷🥁🎻🎺🎤💪🏽❣️
Student Name*

First NameLast Name
Student Age*
Date of Birth*

MonthDayYear
Date
Student Gender Assigned at Birth*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone Number*
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Student Email Address*
example@example.com
Parent/Guardian Name (if student is under 18)*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email Address*
example@example.com
Experience and Goals
Previous Music Experience*

BeginnerIntermediateAdvanced
Goals for Creative Development*
Does your child have any special needs?*
Additional Comments or Special Requests
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Relationship to Student*
Emergency Contact Phone Number*
Please enter a valid phone number.
Terms and Conditions:

As the parent or legal guardian of this student, I hereby enroll him/her in the Mentoring with Music program, which offers basic studio skills training at SUNE Records, located at 1176 W. North St., Lima, OH 45805. I am fully committed to adhering to the terms and conditions outlined within the program. I am aware that any cancellations or rescheduling requests must be submitted to the Executive Director of Mentoring with Music in accordance with their established policies.

To schedule an appointment with Jason Henderson or Liz Whitney, click the link below.

https://book.titan.email/mwmbooking
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Fall Session 2025 Enrollment Form

Welcome! 🥳🎶

Experience and Goals

Emergency Contact Information