Jazz Network Membership Application 2024-2025
Welcome! Thank you for your interest in joining Jazz Network! 

By completing this application, you and your child will be added to our email list to receive our members-only newsletter. Our members-only newsletter is emailed every month and features all of our upcoming programming and services, program highlights, tips & advice from our staff, and much more.

What: A support network for girls that provides positive mentorship, skill development, and networking opportunities to empower the next generation of women leaders

Who: Open to girls ages 11-18 residing in Monroe County

When: We offer year-round programming and services

Cost: FREE to join the network; However, some programs require a participation fee. All programs are first-come, first-served.

Once you complete this application, a representative from our team will reach out to you within five (5) business days via email to schedule an interview. If you have any questions or concerns, please feel free to email Jazz Haywood, Executive Director, at thejazznetworkroc@gmail.com or call 585-290-0907.
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Student Information
Student First Name *
Student Last Name *
Student Cell Number
Student Email Address *
Gender *
Address Line 1 - House Number & Street Name *
Address Line 2 - Apartment, Unit, Building, etc. *
City, State, Zip Code *
2023-2024 School Name *
2023-2024 Grade *
Age *
Race (Check all that apply) *
Required
Hobbies & Favorite Recreational Activities (Check all that apply)
 *
Required
Parent/Caregiver Information
Parent/Caregiver First & Last Name *
Email Address *
Relationship to Student *
Phone Number *
Emergency Contact Information
First & Last Name of Emergency Contact #1
 *
Relationship to Student *
Phone Number *
First & Last Name of Emergency Contact #2
Relationship to Student
Phone Number
Parent/Caregiver Permission to Participate in Jazz Network program(s) and services
Publicity: I give permission for publication of photos/videos of my child (or student for whom I am legal guardian of) in publications produced by Jazz Network including but not limited to the organization website, social media accounts (ex: Facebook and Instagram), e-newsletters, donor/sponsor materials, videos, and media releases. I understand that we will not be paid any royalties or other compensation, and I give up any and all rights my child may have to payment if our/my photo/video is published. Further, refusal to consent to photos/videos will in no way affect the services and/or benefits my child may receive/access. If I have any questions or wish to withdraw my consent in the future, I can do so at any time by contacting Jazz Network. By checking 'Yes' below, I agree to this consent.
 *
Required
Release of Liability: I do hereby give my my child permission to attend and participate in the activities sponsored by Jazz Network. I hereby release the Jazz Network, its officers, directors, employees, contracted employees, independent contractors, instructors, agents, organizers, and volunteers of any and all liability for damage, injury, lost or expense of any kind arising out of or connected with my child's participation. I understand that the Jazz Network is not responsible for any lost or stolen items. 

I understand that in case of a medical emergency, my own personal medical plan will be used. As a condition of participation in the Jazz Network, Inc. programming by the student named in this application, I acknowledge that I have read this consent form, and knowingly, on behalf of my child, assume all of the risks associated with participating in any way in Jazz Network programming.  

 *
Is there anything else you would like to share with us about the student? (allergies, dietary restrictions, medications, accommodations, etc.) 
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