Student Application - The Roots of Music

1a. Last Name-Student

Do not include suffix (Jr, III, etc)

This is a required question

1b. First Name-Student

This is a required question

1c.Middle Name-Student

This is a required question

1d. Suffix

e.g. Jr., II, IV, etc.

This is a required question

2. Date of Birth-Student

3. Gender-Student

Boy
Girl

This is a required question

5. Ethnicity-Student

This is a required question

Student Phone Number

This is a required question

4. Student grade level at the time of application

This is a required question

6. What school is your child attending?

This is a required question

7. What is the address of your child's school?

This is a required question

8. What is the main phone number of your child's school?

This is a required question

9. What time does the applicant's school dismiss?

please answer in this format: 4:05p

This is a required question

10a. Home Address-Student

Only the number and street name.

This is a required question

10b. Home Address-Student (Line 2)

If there is an apartment or unit number.

This is a required question

10c. City

This is a required question

10d. State

This is a required question

10e. Zip Code

This is a required question

11. T-shirt Size-Student

Please use the shirt size of the student at the time of application.

This is a required question

12. Parent/Guardian #1 Name

This is a required question

12a. Relationship with student?

This is a required question

12b. *If you answered [other] to question 12a, please describe your relationship with the applicant?

e.g. Legal Guardian; Brother/Sister, etc.

This is a required question

12c. Parent/Guardian #1 Home Phone Number

please include area code

This is a required question

12d. Parent/Guardian #1 Cell Phone Number

please include area code

This is a required question

12e. Parent/Guardian #1 Other Phone Number

please include area code

This is a required question

12f. Parent/Guardian #1 email address

This is a required question

13. Parent/Guardian #2 Name

This is a required question

13a. Relationship with student?

This is a required question

13b. *If you answered [other] to question 13a, please describe your relationship with the applicant?

e.g. Legal Guardian; Brother/Sister, etc.

This is a required question

13c. Parent/Guardian #2 Home Phone Number

please include area code

This is a required question

13d. Parent/Guardian #2 Cell Phone Number

please include area code

This is a required question

13e. Parent/Guardian #2 Other Phone Number

please include area code

This is a required question

13f. Parent/Guardian #2 email address

This is a required question

14. Emergency Contact Person #1 Name

In case parent/guardian can not be reached in the event of an emergency.

This is a required question

14a. Relationship to Student

This is a required question

14b. Emergency Contact Person #1 Phone Number

please include area code

This is a required question

15. Emergency Contact Person #2 Name

In case parent/guardian can not be reached in the event of an emergency.

This is a required question

15a. Relationship to Student

This is a required question

15b. Emergency Contact #2 Phone Number

please include area code

This is a required question

16. Please list any known medical conditions or ailments to consider regarding the applicant. If there are none to list, please type "N/A"

All ROM students are subject to physical activities that range from moderate to strenuous. It is important that we are aware of any medical conditions, or ailments that may require exclusion from certain activities.

This is a required question

16a. Please list any physical limitations. If there are none to list please type "N/A"

All ROM students are subject to physical activities that range from moderate to strenuous. It is important that we are aware of any limitations that your child may have in order to accommodate.

This is a required question

17. Does the applicant have any dietary restrictions?

Must select at least 1 options.

This is a required question

18. Please list any known allergies.

This is including but not limited to allergies to certain medication, food allergies, and/or plant/insect allergies. If there are no known allergies to list, please type "N/A."

This is a required question

19. Which instrument does the applicant wish to learn? Chose TWO sections

Based on availability. ROM instructors reserve the right to place students where deemed appropriate.

Upper Brass (Trumpet, Mellophone)
Lower Brass (Trombone, Baritone Horn, Sousaphone/Tuba)
Woodwind (Clarinet, Saxophone, Flute)
Percussion (Drums & Cymbals)

Must select exactly 2 options.

This is a required question

20. The Roots of Music Inc. offers daily bus transportation at no cost to you. Please check any/all boxes that apply.

Bus service is provided by a trusted third party contractor. Service may be limited to certain areas. Some restrictions may apply.

I will NOT require bus service for the applicant.
This applicant requires bus service from his/her school to ROM during weekday programming (Mon-Thu).
This applicant requires bus service from ROM to Home during weekday programming (Mon-Thu).
This applicant requires bus service to and from ROM on the weekend (Sat).

Must select at least 1 options.

This is a required question

20. Does the applicant receive free, or reduced lunch at his/her school?

Yes, the applicant recieves free/reduced lunch.
No, the applicant does not receive free/reduced lunch.

Must select at least 1 options.

This is a required question

21. Does the applicant have any social, emotional, or behavioral needs that should be brought to the attention of ROM staff?

Some ROM students have BIPs, IEPs, and 504 classifications. We take pride in serving the needs of ALL of our students. Please request a private meeting if you would like to discuss any considerations that the applicant may require. Please trust that care is taken to maintain confidentiality regarding all applicants/students.

Yes. Please have someone from your staff contact me for a private conference.
No. No accommodations are needed.

Must select exactly 1 options.

This is a required question

22. If there is any other information that you would like to be considered in this application, please provide it below.

This is a required question

By submitting this application, the applicant is not guaranteed a spot in The Roots of Music. Once applications are submitted, they are reviewed by our staff. Parents/Guardians will be notified by a ROM representative, and given a date when the applicant may start attending the program. There will be documents for the parent/guardian to sign and return before the applicant is allowed to fully participate.

"I have read the above text and agree."

This is a required question