Music Clubhouse Application | Hyde Square Task Force

Program Selection

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: 8-18] (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 Information

Name:*

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):*

Income 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?*

Were you previously enrolled in a Hyde Square Task Force program?*

Yes
No

If yes, which program?*

Parent / Guardian 1 Information

Parent / 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:*

Employment Status:*

Employed
Self-employed or business Owner
Unemployed

Employer:*

Occupation:*

Work Phone Number:

Emergency Contact Information

Emergency Contact 1:*

First Last

Relationship to youth:*

Phone Number:*

Emergency Contact 2:

First Last

Relationship to youth:

Phone Number:

Medical Information

Do 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*

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*

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*