Girls Rock! RI Youth Group Lessons Fall 2017 Registration Form
Hello future rockers (and parents/guardians)!

This registration form is for Youth Group Music Lessons with Girls Rock! Rhode Island. Please fill out this form to get your rocker on board. Participants must be 11-18 years old (or currently in 5th-12th grade). We welcome girls, women, trans, and gender non-conforming individuals in our programming.

All lessons will be held at our program space at 769 Westminster Street on the West Side of Providence. Lessons will start the first week of October and run for 10 weeks, culminating in a community concert on Saturday, December 16th.

Mondays 5:15-6:15pm /// Intro to Vocals with Emily Goldstein
Tuesdays 4:30-5:30pm /// Intro to Bass Guitar with Ash Russell
Wednesdays 5:15-6:15pm /// Beginner/Intermediate Guitar with Karen Orsi
Thursdays 4:30-5:30pm /// Intro to Keyboards with Khym Carmichael
Sundays 12:00-1:15pm /// Beginner Drums with Rachel Blumberg

More info and class descriptions here: http://girlsrockri.org/register-grouplessons/

Don't forget to click "submit" at the end of the form to complete the registration! We will follow up with you about payment and financial aid requests.

Thanks!
Girls Rock! RI

Participant Info!
Youth participant's first name
Your answer
Youth participant's last name
Your answer
Name you prefer to be called by instructors
If different than above
Your answer
Youth participant's email address
Your answer
Youth participant's phone number
Your answer
Street Address
Where you receive mail
Your answer
Apartment/unit/floor #
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Age
Participants must be 11-18 years old to attend Youth Group Lessons
Your answer
Date of birth
MM
/
DD
/
YYYY
Grade
School attending
Your answer
What type of school is this?
Parent/Guardian Contact Info!
First name of primary contact/parent/guardian
Your answer
Last name of primary contact/parent/guardian
Your answer
Relationship to participant
Your answer
Primary contact's phone number(s)
Cell
Your answer
Home
Your answer
Work
Your answer
Primary contact's email address
We use email as our main mode of communication so please submit an email address that you check frequently
Your answer
What is the best way to contact you?
First name of secondary contact
In case of emergency only.
Your answer
Last name of secondary contact
In case of emergency only.
Your answer
Relationship of secondary contact to participant
Your answer
Secondary contact's phone number(s)
Cell
Your answer
Home
Your answer
Work
Your answer
Secondary contact's email address
Your answer
What is the relationship of the secondary contact to the primary contact?
Your answer
About Music and More!
What class does your child want to take?
(If they want to take more than one class, please fill out a separate form for each class)
How long has your child played this instrument?
Playing/practicing regularly
What is your child's level of experience with this instrument?
If your child has played this instrument before, how did they learn to play it?
Select all that apply
Required
Has your child attended Girls Rock! Rhode Island's Girls Rock Camp before? If so, when?
Select all years attended
Required
If your child has attended Girls Rock Camp before, what instrument did they play in their band?
Select all that apply
Who are 3-5 of your child's favorite bands/artists?
Your answer
How did you hear about Girls Rock! RI's Group Lessons?
Your answer
If we offered other instruments through our group music lessons, what else would you like to learn?
Your answer
More About Your Child!
Demographics, medical issues, etc. (To be completed by a parent/guardian)
Racial/ethnic identity (optional)
Creating a group of participants that reflects the diversity of Rhode Island is a priority for our programming. In addition, some of our funders require the racial/ethnic and economic make-up of our program population to be documented. Providing the following information will help us meet our diversity goals and help us continue to receive funding for future sessions. Check any that apply.
Language needs
Does your child have difficulty understanding lessons in English? If your child is in need of language interpretation, we will do our best to accommodate. Please indicate your child's first language here:
Your answer
Medical conditions/allergies/dietary restrictions
Does your child have any medical conditions, allergies, dietary restrictions, or other issues that the staff should know about? All medical information will be kept confidential and shared only with necessary staff.
Your answer
Behavioral/emotional/social issues
Does your child have any behavioral, emotional, or social issues the staff should know about? We ask so that we can best serve our participants and have adequate staff on hand if special attention is needed. Again, all personal information will be kept confidential and shared only with necessary staff.
Your answer
Does your child have friends or relatives who are also attending Group Lessons?
If so, please list their name(s) below:
Your answer
Gear Loan!
Your child will need to have a guitar or bass to bring to lessons and practice at home. Drums, amps, and keyboards will be provided by Girls Rock! RI to use during lessons, but you will also need something at home to practice on. If you do not have your own instrument, you can borrow a guitar, bass, keyboard, amp, or drums through our Gear Loan Program (pending availability). There is a small deposit required, which will get refunded when you return the instrument.

No instrument is needed for vocal lessons - your voice is your instrument! Please select "No" if you are signing up for the vocals class.

Are you interested in borrowing an instrument for your child during Group Lessons?
Payment and Financial Aid
Tuition for the Fall Session of Group Lessons is
---$250 for the vocal, bass, guitar, or keyboard class
---$280 for the drum class

We have need-based financial aid available to offset the cost for those who are unable to pay full tuition.

If you would like to request a full or partial scholarship to offset the cost, please indicate here and fill out the following section. If you are interested in receiving financial aid but are unsure if you qualify, please go ahead and complete this section. We will follow up with you to confirm whether we can provide a scholarship for you.

Would you like to apply for financial aid?
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