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.Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

PARTICIPANT INFORMATION

HOUSEHOLD INFORMATION