Música Franklin Registration 2023-2024 Intermediate Ensemble

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Please note: this form is for the confidential administrative records of Música Franklin and will not be shared with or distributed to any other entity for any purpose. Completion of this form is REQUIRED for participation in Música Franklin programs.

Música Franklin is a free after school music program for students in elementary, middle, and high school. This registration form is for the intermediate ensemble only, which is open to middle and high schoolers in Franklin County with prior experience playing stringed instruments. The program will meet each week on Wednesdays at the First United Methodist Church in Greenfield starting on Wednesday, September 20th.

Wednesday 2:30-4:15 - Intermediate ensemble rehearsal

Wednesday 4:15-5:00 - Individually scheduled times for semi-private strings lessons

Tuesday/Thursday 2:30-3:30 - Individually scheduled times for semi-private strings lessons

Parents are required to attend our annual parent meeting and first Community Concert at the First United Methodist Church on October 4th, 4:30-6pm. The parent meeting, which takes place from 4:30-5pm, will provide information about the program and program guidelines. Afterwards, from 5-6pm, the Community Concert will take place. Community Concerts are bi-monthly showcases of the music students have been working on in the program, and guest artists may also perform. Food is provided for families in attendance.

Masks are required for anyone in the program who is exhibiting symptoms of Covid-19, and physical distance will be maintained at all times.

First United Methodist Church

25 Church St

Greenfield, MA

Students must commit to coming every day the program meets. If your child is sick or has a medical or family emergency, please call Música Franklin at 413-475-6681 to request an excused absence. If there are more than 3 unexcused absences total, your child will be placed on the wait list so we can allow another child the opportunity to join. Contact us at 413-475-6681 or info@musicafranklin.org with any questions.

Student Name *

Grade Level: *

Birth Date: *

YYYY

Gender: *

Male

Female

Non-Binary

Other:

What school does your child attend? *

T-shirt size: *

Youth X-Small

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult X-Large

Adult 2X-Large

Musical Experience other than Música Franklin, if any: *

Please list any known allergies, food sensitivities or dietary restrictions:

Additional Children: Please list name, grade, gender, birthdate, school, allergies/food sensitivities, t-shirt size, and musical experience for any additional children from the same household who are enrolling.

Will your child also participate in the regular Greenfield program on Tuesdays and Thursdays? If you are enrolling multiple children, please write the names of children enrolling in both the intermediate ensemble AND the regular Greenfield program.

Yes, my child will also come to Música Franklin on Tuesdays and Thursdays

No, my child will only participate in the Wednesday intermediate ensemble

Other:

If we need to shift to REMOTE days, do you have access to a zoom-compatible device and internet connection for your child to participate? *

Yes, I have both

I have internet but need a device for my child

I have a device but need help with internet connection or data

I need help with a device AND with internet connection

Would you like to receive monthly emailed newsletters to hear about Música Franklin program offerings and updates?

Yes

Clear selection

Parent/Guardian 1 Name *

Parent/Guardian 1 Address *

Parent/Guardian 1 Town *

Parent/Guardian 1 Zip Code *

Parent/Guardian 1 Home Phone (10 digits) *

Can this phone receive texts? *

yes

Parent/Guardian 1 Work Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 1 Other Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 1 Email (if no email, write "none") *

Parent/Guardian 1 Preferred Contact Method *

Call Home Phone

Text Home Phone

Call Work Phone

Text Work Phone

Call Other Phone

Text Other Phone

Parent/Guardian 2 Name

Parent/Guardian 2 Address

Parent/Guardian 2 Town

Parent/Guardian 2 Zip Code

Parent/Guardian 2 Home Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 2 Work Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 2 Other Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 2 Email

Parent/Guardian 2 Preferred Contact Method

Call Home Phone

Text Home Phone

Call Work Phone

Text Work Phone

Call Other Phone

Text Other Phone

Clear selection

Emergency Contact if we are unable to reach parent/guardian 1--Full Name *

Emergency Contact--Phone *

Authorized pick-up: list all individuals authorized to pick your child(ren) up from Música Franklin programs. Please list FULL NAME and PHONE. Your child will ONLY be released to a parent/guardian listed on this form or those listed below. *

Photo and Video Release: By checking below, I give permission for my child to appear in public photos and videos taken by Música Franklin, or a person authorized by Música Franklin. We will never identify students by their full name. *

I DO give permission for my child to appear in public photos and videos. This may include Música Franklin's e-newsletters, web site, and promotional materials, local newspapers, community television, social media, and more.

I DO NOT give permission for my child to appear in any public photos or videos

Confidential Portion: The following questions are important for our records and for the funding Musica Franklin receives. The answers you provide are completely confidential and will never be used except as anonymous, aggregated statistics. Your cooperation in providing this information is very much appreciated.

Student Ethnicity (please check all that apply):

Latin American

Black or African American

Native American or Native Alaskan

Native Hawaiian or Pacific Islander

Asian

White

Prefer to Not Say

Other

Primary Language Spoken at Home:

Household Size:

CONFIDENTIAL: The following question is important for our records and for the funding Música Franklin receives. The answers you provide are completely confidential and will never be used except as anonymous, aggregated statistics. Your cooperation in providing this information is very much appreciated.

Is your child diagnosed with a physical, mental or learning disability or have an IEP at school?

Yes

Prefer to Not Say

Clear selection

Does your family qualify for (please check all that apply):

SNAP

free/reduced school lunch

Medicaid

Health care premium assistance

Prefer not to say

CONFIDENTIAL: The following question is important for our records and for the funding Música Franklin receives. The answers you provide are completely confidential and will never be used except as anonymous, aggregated statistics. Your response is optional. Your cooperation in providing this information is very much appreciated.

Please list your total annual household income:

Authorization for Field Trips and Transportation (please check any that apply. If not checked, your child will not be allowed to participate in that activity).

I authorize my child to participate in a "walking bus" from school to the First United Methodist Church on program days. I understand children will be accompanied by at least two supervising adults while walking and program staff will carry emergency contact information for each participating child.

I authorize my child to participate in walking field trips during regular program hours. I understand children will be accompanied by at least two supervising adults while walking and program staff will carry emergency contact information for each participating child. Special field trips outside of regular program hours will have separate permission forms.

I authorize my child to participate in driving carpools to and from the program. I understand that all vehicles will be operated by licensed drivers and carry minimum liability insurance as required by Massachusetts law. I hereby release Música Franklin, as well as its directors, officers, administrators, employees or any other agents from all liability or damages from any and all injuries arising from the negligence of any of the above while traveling for this activity via private transportation.

I will provide my child's transportation to and from daily program.

I authorize my child to walk/bike/bus to and from the program on their own (age 12+ only).

Other:

I have read and agree with the following Program Requirements: *

I understand that Música Franklin will adhere to all COVID-19 safety precautions and agree to have my child wear a secure-fitting face mask that covers nose and mouth when asked while participating in Música Franklin programs during the pandemic.

I understand that my child may not participate if they have had a fever, sore throat, cough, or other COVID-like symptoms in the previous 3 days, have had known contact with a person testing positive for COVID-19 within the past 14 days, or have traveled to a non-exempt region outside the state within the past 14 days. I agree to keep my child home if s/he is not feeling well.

I understand the program is in flux and subject to change due to the unique circumstances of COVID-19. Música Franklin will endeavor to keep families apprised of any changes in a timely manner.

I understand that Community Concerts are a time to celebrate the students’ achievements and support their work, and it is important for me to be there.

I understand that there is some risk associated with any in-person activities during the pandemic regardless of precautions.

I agree to assume full responsibility for my child and hereby release Música Franklin and its representatives from any and all liability associated with my child's participation in the program.

I understand that Música Franklin does not employ medical staff. If a child requires emergency medical care during the program, we will call 911.

Required

By typing/signing my name below, I agree to all the above terms and conditions. *

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