Join Our Music Program Please enable JavaScript in your browser to complete this form.Student Name *Primer NombreApellidoGender or PronounsBirthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student's Preferred Language *Please choose the ethnicity that best describes the student (this information will ONLY be used for statistical purposes. It will NOT be used as a basis for admission or any other discriminatory manner) *Latino(a) or HispanicBlack or African-AmericanAsianPacific IslanderCaucasian/WhiteOtherIf you indicated "other" please specify belowAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSchool *Student Grade *Student's Living Arrangement *Living with Parent(s)Living with other family membersFoster care/parent(s)OtherDoes the student qualify for free or reduced lunch? *YesNoParent/Guardian #1 Name *Primer NombreApellidoCell Phone Number *Work Phone- if applicableEmail *Parent 1 Preferred Language *Do you feel comfortable communicating in English? *YesNoAddress- leave blank if same as student addressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent/Guardian #2NamePrimer NombreApellidoCell PhoneEmailParent/Guardian 2 Language PreferenceDo you feel comfortable communicating in English?YesNoAddress- leave blank if same as student address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is your annual household income? Less than $25,000$25,000-$49,000$50,000-$75,000Over $75,000Prefer not to answerThis question is optional and does NOT affect your child's enrollment in the program. This information helps us when we apply for grants so we can keep Global Arts free for our community. People Authorized for Pick-UpPlease list who is authorized to pick-up your child. By law, we cannot release your child to someone who is not a parent or legal guardian unless you have given us prior written authorization to do so.NamePrimer NombreApellidoPhoneName Primer NombreApellidoPhoneEmergency InformationEmergency Contact #1 (other than parent or guardian) *Primer NombreApellidoCell Phone Number *Emergency Contact #2 (other than parent or guardian)Primer NombreApellidoCell Phone NumberPlease list any allergies or medical conditions your child has. May your student be given the following if needed?Aspirin or Tylenol *Yes NoBenadryl *Yes NoMedical Authorization Should it be necessary for the student, parent(s), and/or guardian listed above to receive medical care while participating with Global Arts and/or any activities with which it is affiliated, I/we hereby give Global Arts personnel permission to use their judgement in obtaining that care. I/We also give permission to the physician selected by Global Arts personnel to render medical care that s/he deems necessary and appropriate. I/We understand that Global Arts has no insurance covering medical or hospital costs incurred by any participant and, therefore, any cost incurred for such treatment will be entirely my/our responsibility.Submit
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