Sistema Utah 2017-18 Registration Form
West Valley 1 Campus
Email address
Student Name (First and Last Name)
Your answer
Student Grade
Your answer
Did your student participate in Sistema Utah this past school year (2016-2017)?
Required
Student Instrument (all students take a singing class and must pick an additional instrument to learn. Email Mrs. McCullough cmccullough@apamail.org for questions)
Required
Guardian Full Name
Your answer
Guardian Phone Number
Your answer
Guardian Home Address
Your answer
Guardian Email Address
Your answer
Emergency Contact #1 Name, Phone Number, and Relationship
Your answer
Emergency Contact #2 Name, Phone Number, and Relationship
Your answer
Does your student have any food, medicine, and/or environmental allergies?
Required
If yes, please list allergies and appropriate procedures for aiding the student in case of allergic reaction:
Your answer
Name of Doctor and Contact Information
Your answer
I understand that the program hours run MTF 3:50-6:30 and W/Th 2:50-5:30. It is my responsibility to pick up my children no later than 10 minutes following the conclusion of program day.
Required
Who will be picking up your students each evening? Please include up to 3 separate adults with full name and contact information.
Your answer
I understand that any exit from the Sistema Utah Program requires an in-person interview with Mrs. McCullough to maintain accurate grant records.
Required
By checking "yes" below I agree to allow my student to be recorded/filmed/photographed for Sistema Utah purposes. This may include audio recordings, photographs, video recordings, advertisements, and Sistema Utah website use.
Required
By checking "yes" below I commit to providing an instrument for my student. If I do not have the means to provide an instrument for my student I will notify Mrs. McCullough immediately so that she can assist in finding an instrument for my student to use.
Required
I understand that my student can only attend one after school activity per week (i.e. clubs, extra curricular activities). I understand that this is a music program and that I will have my student attend regularly.
Required
Please communicate any additional information or schedule questions below (i.e. my student needs to check out an hour early every Tuesday, or my child needs an extra homework class beyond the offered 25 min before Sistema and 25 min at the end of Sistema.)
Your answer
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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