Uptown Music Collective - STOMP - New Student Application
This form is to be completed by a parent of a student wishing to receive lessons through the Uptown Music Collective’s STOMP (Student Teacher Outreach & Mentoring Program).
First and Last Name of Student: *
First and Last Name of Parent/Guardian/ Contact: *
Gender *
Student's Current Age: (Must Be the ages of 5 – 10 years old) *
Student's Date of Birth (MM/DD/YR): *
MM
/
DD
/
YYYY
Student Ethnicity *
This information is only used for demographics about the school for grants and fundraising.
Student's Address: *
Please list your street/mail box number, street name, city/town of residence, state and zip code. Please use the student's primary address.
What county does the student reside in?
This information is only used for demographics about the school for grants and fundraising.
Student's Home Phone #: *
Please include area code. Ex:000-000-0000
Parent's or Emergency Contact's Cell Phone #: *
Please include area code. Ex:000-000-0000
Parent's/Contact's Email Address *
What school does the student attend? (If applicable) *
What instrument does the student wish to receive lessons on? (Please choose 1st instrument choice)
This is based on what can be provided each semester since our student teachers are volunteers. We will have loaned instruments that students can borrow while being involved in STOMP.
Clear selection
What instrument does the student wish to receive lessons on? (Please choose 2nd instrument choice)
This is based on what can be provided each semester since our student teachers are volunteers. We will have loaned instruments that students can borrow while being involved in STOMP.
Clear selection
Do you have any previous experience with that instrument? If so, how much? *
Does the student have any health or learning issues that we need to be aware of?
Ex: Allergies, disorders, medical conditions, etc.
I hereby give my consent to the Uptown Music Collective to use photos and videos (including live streams) of my child for publicity and promotional purposes. *
Questions or Comments?
Please list any questions you might have. Program Assistant, Breanne Eisenhardt will contact you with the lesson availability. This program will be served on a first come first served basis.
Submit
Never submit passwords through Google Forms.
This form was created inside of Uptown Music Collective.