PART 1
To be completed by the parent

Student First Name

Student Last Name

Date of Birthday (dd-mm-year)

Current Grade (2021 - 2022)

Grade (2020 - 2021)

Primary Instrument

Secondary Instrument

Woodwind Doubles

Parent(s) or Guardian(s) first name(s):

Parent(s) or Guardian(s) last name(s):

Home Phone Number:

Work Phone Number:

Parent Cell (1):

Parent Cell (2):

Parents Email (1):

Parents Email (2):

Mailing Address

Street:

City:

State:

Zip Code:

Name of School:

Name of Music Program (if applicable):

Music Teacher, Band Director, or Guidance Counselor’s Name:

PART 2

I, the parent or guardian, certify to the best of my ability that the information in this application is correct, and electronically sign my name below: