2022-2023: Music Clubhouse Application I would like to participate in the following session(s):* Fall Session Spring Session Check which lesson(s) you are interested in.**Please note that there is a $25 enrollment fee for each instrument each session. Drum Lessons Voice Lessons Guitar/Bass Lessons Piano Lessons Participant InformationName:* First Last Date of Birth:* Month Day Year Age:* Gender:* Female Male Non-Binary Gender Questioning Gender Transitioning Other Address:* Street Address Apartment Number (Write "N/A" if this does not apply to you) City State / Province / Region ZIP / Postal Code Home Phone Number:*Cell Phone Number:*Email Address:* Race/Ethnicity* Asian or Pacific Islander Black or African American Hispanic or Latino Native American or Alaskan Native White or Caucasian Multiracial or Biracial Other Country of Origin:* Please select your household size (make sure to include yourself):*1 Person2 Persons3 Persons4 Persons5 Persons6 Persons7 Persons8 Persons or moreSelect the income range that best describes your household below (either column 1, 2, or 3).*Column 1Column 2Column 3None (outside income range)What school do you 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 Apartment Number (Write "N/A" if this does not apply to you) 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 InformationDoes your child have health insurance* Yes No If you selected "yes," please fill in below your health insurance provider. If you selected "no," respond with N/A:* If you selected "yes," please fill in below the name of the policyholder, if you selected "no," respond with N/A:* If you selected "yes," please fill in below the policy number, if you selected "no," respond with N/A:* Please select any of the following medical conditions your child has:*AsthmaDiabetesADHDSeizuresAnxiety/DepressionMental Health Diagnosis - If your child has a particular diagnosis please detail it in the question below.OtherNoneIf you selected "other" to the question above, please provide details below:Does your child have any allergies?*YesNoIf you selected "yes" to the question above, please list them below:Does your child use any of the following?*InhalerEpipenInsulinSelf-administered medicationOtherNoneIf you selected self-administered medication or other, please list below: Are you concerned about a medical condition that will potentially prohibit your child's participation at HSTF?*YesNoIf you selected "yes," please explain below.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. You DO NOT have my consent. Parent/Guardian Signature:* Date* 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* MM slash DD slash YYYY Photo/Video Consent and Release Form (Youth and Parent/Guardian)Promotional Release: I hereby give permission for Hyde Square Task Force to use for educational and/or publicity purposes only any photographs, film, or video taken of my child during the course of his or her participation in Hyde Square Task Force programming. I understand that my child and/or any other identifying information may be used in accounts of the Hyde Square Task Force programs, including newspaper and magazine articles, social media, 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 any 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.Do you grant photo and video consent to Hyde Square Task Force as outlined above?YesNoParticipant Signature:* Parent/Guardian Signature:* Date* MM slash DD slash YYYY Δ
