2019-2020: Music Clubhouse Application I would like to participate in the following session(s):* Fall Session Spring Session Please select the program(s)* that you are applying to:* Music Clubhouse (ages 8-14) Check which lesson(s) you are interested in.**Please note that there is a $25 enrollment fee for each session. Drum Lessons Voice Lessons Guitar/Bass Lessons Piano Lessons Participant InformationName:* First Last Date of Birth:* MM DD YYYY Age:*Gender:* Male Female Other Address:* Street Address City State / Province / Region ZIP / Postal Code Home Phone Number:*Cell Phone Number:*Email Address:* Race (Check all that apply):* Black White Latino Asian Other Ethnicity:*Country of Birth:*Please select your household size (make sure to include yourself):*1 Person2 Persons3 Persons4 Persons5 Persons6 Persons7 Persons8 Persons or moreIncome Bracket:* $0 to $20,650 $20,651 to $34,350 $34,351 to $51,150 Income Bracket:* $0 to $23,600 $23,601 to $39,250 $39,251 to $58,450 Income Bracket:* $0 to $26,550 $26,551 to $44,150 $44,151 to $65,750 Income Bracket:* $0 to $29,450 $29,451 to $49,050 $49,051 to $73,050 Income Bracket:* $0 to $31,850 $31,851 to $53,000 $53,001 to $78,900 Income Bracket:* $0 to $34,200 $34,201 to $56,900 $56,901 to $84,750 Income Bracket:* $0 to $36,730 $36,731 to $60,850 $60,851 to $90,600 Income Bracket:* $0 to $40,890 $40,891 to $64,750 $64,751 to $96,450 If your selected household generated an income outside of the Income Bracket, please provide your income here:What school do you currently attend?*What grade are you in?*Have you previously enrolled in Music Clubhouse?* Yes No Parent / Guardian InformationParent / Guardian Name:* First Last Relationship to youth:*Address:* Street Address City State / Province / Region ZIP / Postal Code Home Phone Number:*Cell Phone Number:*Email Address:* Parent / Guardian Country of Birth:*Emergency Contact InformationEmergency Contact 1:* First Last Relationship to youth:*Phone Number:*Emergency Contact 2: First Last Relationship to youth:Phone Number:Medical InformationDo you have medical coverage?* Yes No Insurance Policy (Name):*Policy #:Does your child/teen have any of the following:*Please check all that apply. Allergies Physical difficulties Medications an IEP a 504 plan Emotional/behavioral challenges Learning challenges Mental health diagnosis None Allergies* Food Environment Medical Other If other, please elaborate:*If you have a food allergy, please name it:*If you have an environmental allergy, please name it:*If you have a medical allergy, please name it:*If physical difficulties, please describe:*If your child/teen is on medications, please elaborate:*If your child/teen is on an IEP, please describe:*If your child/teen is on a 504 plan, please describe:*If your child/teen has emotional/behavioral challenges, please describe:*If your child/teen has an learning challenges, please describe:*If your child/teen has a mental health diagnosis, please describe:*Medical Consent*I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take my child to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my child's health. You have my consent Parent/Guardian Signature:*Date* Date Format: MM slash DD slash YYYY Consent*The information provided on this form is true and accurate to the best of my knowledge and I give permission for my son/daughter to participate in Hyde Square Task Force programs and activities. You have my consent Parent/Guardian Signature:*Participant Signature:*Date* Date Format: MM slash DD slash YYYY Photo/Video Consent and Release Form*I hereby give permission for Hyde Square Task Force to use any photographs, film, or video taken of my child during the course of his or her participation in Hyde Square Task Force programming for educational and/or publicity purposes only. I understand that my child and/or any other identifying information may be used in accounts of Hyde Square Task Force programs, including newspaper and magazine articles, website and other internet materials, television, and other presentations or publications concerning the programs. I understand and acknowledge that my consent to the use of the above information is purely voluntary and is not required by Hyde Square Task Force as a condition of my child's participation in Hyde Square Task Force programming. I knowingly and voluntarily release and hold harmless Hyde Square Task Force, its agents and employees from an liability of any kind resulting from use of the information as set forth above. This release and waiver of liability is binding upon my successors, heirs and assigns. Yes (you have my promotional release) No (you do NOT have my promotional release) Participant Signature:*Parent/Guardian Signature:*Date* Date Format: MM slash DD slash YYYY
