2026 Youth Summer Program

Participant Enrollment Form
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 is the child/youth’s current grade level?*
Child/Youth's most recent school*
Student's ID# (if known)
Leave blank if unknown
Student T-shirt Size*
For Field Trips
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
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
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 summer program. *please include dates.*
Would your child be interested in attending the afterschool program after completing the summer program?*
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 workshop without compensation*
Please be advised that during our school summer 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. This information will help us provide appropriate care in case of an emergency.Trained Staff: Our staff members are trained in basic first aid procedures and medication administration. However, they are not medical professionals. In serious medical situations, emergency services will be contacted immediately.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.*
I give permission for my child to participate in summer program field trips. I understand that the institution will take reasonable precautions for the safety and well-being of the students during the trip.*
The Children’s Services Council of Leon County (CSC Leon) funds local organizations and agencies to serve children,
youth, and families. Our goal is to make high-quality services available and affordable throughout Leon County.

To evaluate the effectiveness of CSC Leon–funded programs, CSC Leon may share information about your child’s
participation with the Florida Department of Juvenile Justice (DJJ). DJJ will report back only de-identified, aggregate data
(for example, the percentage of youth not involved with the juvenile justice system). No personally identifiable
information will be returned to CSC Leon.

• Your consent is required in order to participate in CSC Leon–funded programs.
• The information we receive will be used only to measure program outcomes.
• The results will not be used to determine whether your child continues receiving services.

Please complete the section below and sign to provide your consent.

I give my permission for CSC Leon to share information about my child’s participation in CSC Leon–funded programs with
DJJ for the purposes described above
Caregiver's Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Signature*
Should be Empty:

Participant Enrollment Form

PARTICIPANT INFORMATION

HOUSEHOLD INFORMATION