Registration For Youth Beginners Student name Referred by Your level —Please choose an option—BeginnerIntermediateAdvanced Instrument / Class DOB Age Grade as of 2023-242024-25 School Student's Cell Student's Email Extracurricular Activities: Dance Lessons, Drama Plays, Sports, Etc. Mother's Name Mother's Occupation Mother's Home Telephone Mother's Work Telephone Mother's Cell Telephone Mother's Email Mother's Street, city & zip Father's Name Father's Occupation Father's Home Telephone Father's Work Telephone Father's Cell Telephone Father's Email Father's Street, city & zip Parents' Musical Background? MEDICAL INFORMATION & RELEASE (PLEASE LIST ITEMS BELOW) Any Food Allergies? (e.g. Peanut Butter) Any Allergies? (e.g. Dogs, Cats) Any Adverse Reactions to Over-the-Counter-Drugs? (e.g. Tylenol, Advil) Any Other Pertinent Information We Should Know? Emergency Name: Telephone; & Relationship to Student: Doctor’s Name & Telephone: I give permission to administer simple first aid (e.g. Tylenol, Benadryl, antibiotic ointment, etc.) if the need arises for my child. If further medical attention is needed; the parents, the emergency contact, doctor, or 911 will be called. I further release the Leslie Kennedy Piano Studio, LLC from any liability for injuries occurring on the premises. PHOTO/VIDEO RELEASE I hereby give permission for images of my child, captured, through photo, video and digital camera, to be used in brochures, websites, posters, advertisements, or other promotional material for Dynamic Music! / Kennedy Piano Studio, LLC. I further waive any rights of compensation or ownership thereto. BEGINNING STUDENT INFORMATION Any instruments previously studied? NoYes [group instrumentsstudied] How long? What instrument(s)? [/group] Any prior dance lessons, art lessons, etc.? And if so, what? What interests you about learning to play a musical instrument? What types of music do you like to listen to? Or, name some of your favorite songs: Current Extracurricular Activities, (e.g. Play other instruments, Dance Lessons; Drama; Sports; Hobbies, Scouts, etc.): Other information that might be useful to know:
