Step Up - Afterschool Enrichment

PARTICIPANT INFORMATION
Participant's Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
If prefer to self describe please indicate below
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
Homeschool or Private School*
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
Which musical activities does your child enjoy?*
Does your child currently create their own music?*
What inspires your child the most about music?*
Publishing Agreement: I agree to release publishing rights to IMB Music for educational and promotional uses for my contributions in this program without compensation*
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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PARTICIPANT INFORMATION

HOUSEHOLD INFORMATION