Student Application - The Roots of Music

This is the general application to join the Roots of Music (ROM). Please only submit one application per student. For siblings and/or multiple applicants, you must complete a new form. The requirements for admission are as follows:

-Students must be aged 9-14 years.
-Students must live/attend school in Orleans Parish.
-Students must qualify for free or reduced school lunch.

1a. Last Name-Student *

Do not include suffix (Jr, III, etc)

1b. First Name-Student *

1c.Middle Name-Student

1d. Suffix

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

2. Date of Birth-Student *

YYYY

3. Gender-Student *

Boy

Girl

5. Ethnicity-Student

Student Phone Number

4. Student grade level at the time of application *

6. What school is your child attending? *

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

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

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

please answer in this format: 4:05p

10a. Home Address-Student *

Only the number and street name.

10b. Home Address-Student (Line 2)

If there is an apartment or unit number.

10c. City *

10d. State

10e. Zip Code

11. T-shirt Size-Student

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

12. Parent/Guardian #1 Name *

12a. Relationship with student? *

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

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

12c. Parent/Guardian #1 Home Phone Number

please include area code

12d. Parent/Guardian #1 Cell Phone Number *

please include area code

12e. Parent/Guardian #1 Other Phone Number

please include area code

12f. Parent/Guardian #1 email address *

13. Parent/Guardian #2 Name

13a. Relationship with student?

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

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

13c. Parent/Guardian #2 Home Phone Number

please include area code

13d. Parent/Guardian #2 Cell Phone Number *

please include area code

13e. Parent/Guardian #2 Other Phone Number

please include area code

13f. Parent/Guardian #2 email address

14. Emergency Contact Person #1 Name *

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

14a. Relationship to Student *

14b. Emergency Contact Person #1 Phone Number *

please include area code

15. Emergency Contact Person #2 Name

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

15a. Relationship to Student

15b. Emergency Contact #2 Phone Number

please include area code

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.

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.

17. Does the applicant have any dietary restrictions? *

No Food Restrictions

Vegetarian

Vegan

Gluten-Free

Food Allergies (Please list in next question)

Required

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."

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)

Required

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).

Required

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.

Required

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.

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

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."

Required

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