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 How long? What instrument(s)? 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: