Musica Franklin Registration 2019-2020-- Leyden Woods
Please note: this form is for the confidential administrative records of Musica 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 Musica Franklin programs.
Student Name *
Your answer
Grade Level *
Your answer
Age *
Your answer
Gender *
Musical Experience, if any
Your answer
Parent/Caregiver 1 Name (First & Last) *
Your answer
Parent/Caregiver 1 Address *
Your answer
Parent/Caregiver 1 Home Phone *
Your answer
Parent/Caregiver1 Work Phone
Your answer
Parent/Caregiver 1 Cell Phone
Your answer
Parent/Caregiver 1 Email *
Your answer
Parent/Caregiver1 Preferred Contact Method *
Parent/Caregiver2 Name (First & Last)
Your answer
Parent/Caregiver2 Address
Your answer
Parent/Caregiver 2 Home Phone
Your answer
Parent/Caregiver 2 Work Phone
Your answer
Parent/Caregiver 2 Cell Phone
Your answer
Parent/Caregiver 2 Email
Your answer
Parent/Caregiver 2 Preferred Contact Method
Emergency Contact--Full Name & Phone *
Your answer
Photo and Video Release: By checking below, I give permission for my child to appear in photos and videos taken by Musica Franklin, or a person authorized by Musica Franklin. We will never identify students by their full name. *
Required
I have read and agree with the following Program Requirements: *
Required
CONFIDENTIAL: We apologize for asking for the following six questions with sensitive information. It is 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 responses are optional. Your cooperation in providing this information is very much appreciated.
Your answer
Student Ethnicity
Primary Language Spoken at Home
Your answer
Household Size: # Adults
Your answer
Household Size: # Children/Dependents
Your answer
Annual Household Income
Is your child diagnosed with a physical, mental or learning disability or have an IEP at school?
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