Spring Reverb 2026 Enrollment Form

Spring Reverb 2026: Your Sound Starts Here 🎶

Wednesdays Hit Different (3:00–5:00 PM • April 15 – June 3)
Welcome to Spring Reverb 2026! 🥳🎶

Mentoring with Music is all about turning passion into power. Founded by visionary Jason S. Henderson, our program was built on the dream of uplifting Lima’s youth through the unstoppable force of music. For eight weeks, young creators ages 8–18 step into the world of recording, beats, and performance — guided by seasoned music pros who make learning hands‑on unforgettable. It’s not just about skills; it’s about confidence, community, and discovering your own sound. We’re excited to kick off Spring Reverb 2026 with you. Questions? Text or call Liz Whitney at 614‑285‑2777 or email liz.whitney@mentoringwithmusic.org. Your sound starts here. 🎶🔥🎤🥁🎸
Student Information
Student Name*

First NameLast Name
Student Age*
Date of Birth*

MonthDayYear
Date
FemaleMale
Address*

Street Address

Street Address Line 2

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Postal / Zip Code
Student Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Student Email Address*
example@example.com
Experience and Goals
BeginnerIntermediateAdvanced
Goals for Creative Development*
Parent/Guardian Information
Parent/Guardian Name (if student is under 18)*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address*
example@example.com
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Student*
OhioRISE Students

(We Accept Flex Funds!)
Name

First NameLast Name
YesNo
OhioRISE / Flex Funds ID Number
Care Coordinator Information

First NameLast Name
Care Coordinater’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Care Coordinator’s Email
example@example.com
Sponsorship & Tuition Assistance

*FREE Classes for Families on Medicaid. DISCOUNT for Working Families who are fixed/low income but NOT eligible for Medicaid. Fees are determined on a sliding scale based on income.
FAMILY ON MEDICAID: Please upload your Medicaid card (front and back) and a valid state-issued photo ID.

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FIXED OR LOW INCOME: Working but DO NOT qualify for Medicaid—Upload your last three paystubs for proof of income, and a valid state-issued photo ID.

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Tuition Payment for Working Families

(Annual income $50K or above.)

Tuition Payment is based on a sliding scale for families. Returning students receive a 50% discount! Call Executive Director, Liz Whitney, to learn more. 614-287-2777.

USD

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Terms and Conditions:

As the parent or legal guardian of this student, I hereby enroll him/her in the Mentoring with Music program, which offers basic studio skills training at SUNE Records, located at 1176 W. North St., Lima, OH 45805. I am fully committed to adhering to the terms and conditions outlined within the program. I am aware that any cancellations or rescheduling requests must be submitted to the Executive Director of Mentoring with Music in accordance with their established policies.

To schedule an appointment with Jason Henderson or Liz Whitney, click the link below.

https://book.titan.email/mwmbooking
Student/Parent/Guardian Signature*

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Spring Reverb 2026: Your Sound Starts Here 🎶

Welcome to Spring Reverb 2026! 🥳🎶

Student Information

Experience and Goals

Parent/Guardian Information

Emergency Contact Information

OhioRISE Students

Sponsorship & Tuition Assistance

Tuition Payment for Working Families