Music Lab Sign Up Form

1
Student Name* This field is required.
First Name
Last Name
2
Student Date of Birth* This field is required.
Date
Month
Day
Year
3
Student Gender* This field is required.
Man
Woman
Transgender
Non-Binary / Non-Conforming
Prefer Not to Say
Other
4
Student EmailPlease provide the student's email if possible. This is optional.
example@example.com
5
Student Phone NumberIf the student is over 18 years of age, please provide their phone number if possible. This is optional.
Area Code
Phone Number
6
Name of School* This field is required.
7
School Type* This field is required.
Public
Private
Homeschool
Other
8
Student Grade* This field is required.Select the grade the student will be entering in the fall. If the correct grade isn't listed, contact Luke Haefner at lhaefner@jeffcenter.org before continuing the form.
6th
7th
8th
9th (Freshman)
10th (Sophomore)
11th (Junior)
12th (Senior)
9
Parent / Guardian Name* This field is required.
First Name
Last Name
10
Parent / Guardian Relationship to Student* This field is required.Please tell us how you are related to the student.
11
Address* This field is required.Please provide us with your home address. This helps us understand which areas we serve.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Parent / Guardian Email* This field is required.
example@example.com
13
Parent / Guardian Phone Numbers* This field is required.
Home Phone Number
Work Phone Number
Cell Phone Number
Email
14
Primary Emergency Contact* This field is required.The first person we call in the event of an emergency.
Full Name
Relationship to Student
Email
Cell Phone Number
15
Secondary Emergency Contact* This field is required.The person we call in the event of an emergency when we can't make contact with the primary emergency contact..
Full Name
Relationship to Student
Email
Cell Phone Number
16
Student Medical Conditions or Dietary NeedsPlease provide us with any relevant information related to the student's medical or dietary needs. If your student has no medical conditions or needs, continue to the next question.
Huge
Large
Normal
Small
Ok
Ok
17
Student Race / Ethnicity* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Two or More Races / Ethnicities
Prefer Not to Say
Other
18
Primary Language(s)* This field is required.Select any option that the student speaks fluently or near-fluently.
English
Spanish
Mandarin Chinese
French
Arabic
Hindi
Portuguese
German
Russian
Japanese
Prefer Not to Say
Other
19
What Genres Does the Student Like?* This field is required.
Rock
Hip-Hop / Rap
R&B
Soul
Jazz
Funk
Blues
Indie
Metal
Dance
Electronic
Classical
Punk
Folk
Country
Hardcore
Bluegrass
Other
20
Student's Favorite Artists* This field is required.Name a few of the student's favorite musicians / recording artists.
Huge
Large
Normal
Small
Ok
Ok
21
Student's Instruments* This field is required.What (if any) instruments does the student play? (It's perfectly fine if they don't play an instrument.)
Huge
Large
Normal
Small
Ok
Ok
22
How Did You or the Student Hear About Us?* This field is required.This information helps us understand how we best connect with our community. Select as many options as relevant.
Internet / Google Search
Facebook
Instagram
Word of Mouth
Printed Ad
At the Jefferson Center
Email
Television
Radio
Other
23
What Jefferson Center Offerings Interest You?* This field is required.Select any options that interest you or the student.
Masterclasses & Workshops
Attending Live Performances
Recording & Music Production
Music Business Classes
Music Theory Classes
Music Career Presentations
Performing in a Band
Performing as a Solo Artist
Other
24
What Does the Student Want to Get Out of Music Lab?Tell us how we can make this experience as education, fun, and meaningful as possible for the student.
Huge
Large
Normal
Small
Ok
Ok
25
Music Lab Policies* This field is required. To enroll at the Music Lab, you must currently be in 6th through 12th grade and enrolled in school or home-schooled (certified by parent). Occasionally, members outside of this age range may be accepted. Please contact Luke Haefner (lhaefner@jeffcenter.org) directly to inquire about special enrollments. The use of profanity, racial slurs, or references to sex, drugs, and/or violence is strictly prohibited. Clean and appropriate language must always be used by members, both in recordings and conduct while at the Music Lab. The possession, use, or influence of drugs, alcohol, or tobacco products is strictly prohibited and will result in immediate suspension or expulsion. Violence, vandalism, assault, or any other criminal behavior, including the possession of weapons, is strictly prohibited and will result in immediate suspension or expulsion. Disruptive or disrespectful behavior is not allowed anywhere inside or on the property of Jefferson Center. Members are required to respect all equipment (hardware, electronic, etc.) within the Music Lab. Access to the Music Lab equipment is a privilege, not a right. Any misuse of the Music Lab equipment could result in immediate suspension or expulsion. This includes, but is not limited to viewing or downloading inappropriate material on the Music Lab computers or destructive treatment of music/recording equipment. Loitering is strictly prohibited outside or near Jefferson Center or in the surrounding neighborhood. Members are not allowed to access other rooms or offices in Jefferson Center other than restrooms and the rooms/studios in Suite 325, specifically the Music Lab. Food is NOT allowed inside any room or studio within the Music Lab. Drinks may be consumed in the lobby. Members must keep their respective workstation area/room clean and free from clutter. Public or inappropriate displays of affection are strictly prohibited. Friends or guests who are not Music Lab members must be approved in writing by the director at least 48 hours prior to their arrival. Any friend or guest is limited to three total visits per semester before either being required to become a member and/or attend orientation. Maximum occupancy limits for each room will be strictly enforced. Members who do not attend school are not allowed to come to the Music Lab for that day. Staff members may perform random attendance checks. Failure to comply with Music Lab policies may result in exclusion from performances and/or recordings, suspension, and/or expulsion. Consequences are determined by the director per incident. By agreeing to these policies, I understand that I, or my child, may be removed from the program for any infractions. DO YOU AND THE STUDENT AGREE TO ABIDE BY THESE POLICIES?
YESNO
26
Media Release* This field is required.I hereby grant Jefferson Center the right to use, reproduce, distribute, and/or transmit photographs, videotape, and/or recordings of my child, in whole or in part, and permit the use of their name in conjunction with these materials. I acknowledge that such photographs, videotape, and/or recordings of me and any associated materials, printed, electronic, or otherwise, may become part of copyrighted materials that Jefferson Center may distribute to others in furtherance of its educational mission. DO YOU AND THE STUDENT AGREE TO THESE TERMS?
YESNO
27
Discord Parental Consent* This field is required.The Music Lab utilizes a Discord server to enable our students to connect outside of Music Lab hours. This gives them a space to discuss Open Lab, upcoming Music Lab events, music they're listening to, questions about instruments and gear, and more. It also provides a space for Music Lab news and announcements. The server is actively monitored by Music Lab staff. All Music Lab policies, as agreed to previously, remain in-effect within the Discord server. Students may face removal from the server, suspension, or expulsion from the Music Lab if Music Lab policies are breached on the Discord server. By consenting, you allow the student to join the Discord server, and you hold harmless the Music Lab and Jefferson Center Foundation for any damage incurred by participation on the Discord server. Parents / guardians can revoke their consent for Discord by notifying Luke Haefner (lhaefner@jeffcenter.org) in writing. Upon receipt of this notification in writing, consent will be considered revoked and the student will be removed from the server. DO YOU CONSENT FOR THE STUDENT TO JOIN THE DISCORD SERVER AND AGREE TO THE ABOVE PROVISIONS?
YESNO
28
Email ConsentDo you consent to receiving emails from the Music Lab and Jefferson Center regarding your enrollment in Music Lab, upcoming Music Lab and Jefferson Center events, and other such communications? This is necessary to receive communications related to your enrollment.
YESNO
29
Select a Payment Option* This field is required.Fun Fact: At $250, Music Lab costs families only $2.08 per hour for the semester (when considering Open Lab, Music Lab Band, and Open Mics).
I will pay the full tuition for the Fall semester ($250).
I would like to be considered for need-based financial aid.
30
Payment
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Music Lab Enrollment Fall 2026
Edit
Back
Total cost
Debit or Credit Card
Should be Empty: