Student Application 4.0 Form

Welcome!
3R9M MUSIC BUSINESS & TECHNOLOGY PROGRAM

The Ann Cephus Family Fund presents the Three Roles in 9 Months (3R9M) Music Business & Technology Program. 3R9M is an internship program for rising 10th and 11th grade high school music creatives and technologists.

Our objectives are to:
- Train a Creative Workforce: Equip students with the essential skills and knowledge through cutting-edge technology and innovative educational practices.
- Establish Sustainable Creative Careers: Empower students to build enduring careers in the creative industries, promoting economic stability and personal fulfillment.
- Foster Innovation and Community Engagement: Encourage students to engage with their communities and lead innovative projects that contribute to cultural and economic development.
This program is offered at no cost to interns. However, to remain in the program, the following criteria must be met.
1. Interns must remain truant all day. No Skipping or excessive absences!
2. Interns must bring any failing grades to passing within 6 to 9 weeks of starting the program.

Student Name*

First NameLast NameSuffix
Enter Personal Email Address and click "Verify Email"*
*NOTE: You may not use your school email address. Use your personal email addresses; preferably GMAIL.
Student Mobile Number*
Please enter a valid mobile number.
Student Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Metro Atlanta High School Name*
If non-Gwinnett High School, enter High School Name.
**Only Metro Atlanta HS Students will be considered.
Select your grade level*
List any Food/Airborne Allergies
Leave blank if none.
Emergency Contact
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Student Headshot Photo
Be sure the photo is clear with no logos or hats*

Upload size may not exceed 50MB
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Transcript Request
Copy of Latest School Transcript (Unofficial Copy is Ok)*

Upload size may not exceed 50MB
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Student Signature

Background Information
Please describe any prior experience or education you have in music, music business, or music technology. If NONE, type N/A*
Maximum 300 words
Please list any software tools you are familiar with (e.g., DAWs, music production software, etc.). If NONE, type N/A*
Maximum 300 words

Parent/Guardian Consent
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
Parent/Guardian Phone Number*
Please enter a valid phone number.
NOTICE OF RIGHTS UNDER

HIPAA AND FERPA

The Health Insurance Portability and Accountability Act (HIPAA) and the
Family Educational Rights and Privacy Act (FERPA) are federal laws that
protect the privacy of your child's health information and education records,
respectively. You have the following rights under these laws:

HIPAA Rights
- The right to access and obtain a copy of your child's health
  information
- The right to request a correction to your child's health information
- The right to request that your child's health information be shared
  with certain individuals or entities
- The right to file a complaint with the U.S. Department of Health and
  Human Services if you believe your child's privacy rights have been
  violated
FERPA Rights
- The right to inspect and review your child's education records
- The right to request that your child's education records be amended
  if they are inaccurate or misleading
- The right to consent to the disclosure of your child's education
  records, except in certain circumstances
- The right to file a complaint with the U.S. Department of Education if
  you believe your child's privacy rights have been violated
Media Release
Transportation Release
Terms and Conditions
Parent/Guardian Signature
Should be Empty: