Registration For Youth Transfers 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 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. STUDENT INFORMATION How many years studied? Dates studied? Method Books Used (Alfred; Hal Leonard; Faber; etc.): Repertoire Studied (Beethoven; Haydn; Mozart; etc.): Participation in Festival: (Years; Ratings; Levels; Teacher): Participation in Guild Auditions: (Years; Levels): Participation in Competitions: (Please List Competitions): Current Extracurricular Activities, (e.g. Play other instruments, Dance Lessons; Drama; Sports; Hobbies, Scouts, etc.): Other information that might be useful to know: