Uptown Music Collective - UMC Program -             New Student Information Form
Please fill out this form to get you or your student signed up at the Uptown Music Collective for the UMC Program.  This form provides us basic contact information for communication and enrollment purposes.  All this information is held privately by our Admissions Director.
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First and Last Name of Student: *
First and Last Name of Parent/Guardian/ Contact: *
If you are filling this out for your child or someone under 18 years old, please list the student's parent/guardian in this space.  If you are over 18 years old and filling this form out for yourself, please list an emergency contact in this space.
Gender *
Student's Current Age: *
Student's Date of Birth (MM/DD/YR): *
MM
/
DD
/
YYYY
Student Ethnicity *
This information is only used for demographics about the school for grants and fundraising.
Student's Address: *
Please list your street/mail box number, street name, city/town of residence, state and zip code.  Please use the student's primary address.
What county does the student reside in?
This information is only used for demographics about the school for grants and fundraising.
Student's Home Phone #: *
Please include area code. Ex:000-000-0000
Student's Cell Phone #: (If applicable) *
Please include area code. Ex:000-000-0000
Parent's or Emergency Contact's Cell Phone #: *
Please include area code. Ex:000-000-0000
Student's Email Address: *
Parent's/Contact's Email Address *
What school does the student attend? (If applicable) *
What instrument do you wish to receive lessons on?
Please select 1.  If you are interested in lessons on multiple instruments, please explain this in the "Questions or Comments" section at the bottom.
Clear selection
What are your preferred days and times for private lessons? *
The Uptown Music Collective teaches private lessons Monday-Saturday.  Days and times available for lessons depends on teacher availability.
Do you have any previous experience with that instrument? If so, how much? *
What styles of music do you listen to? *
Rock, Pop, Blues, Jazz, Alternative or list Artists
Does the student have any health or learning issues that we need to be aware of?
Ex: Allergies, disorders, medical conditions, etc.
I hereby give my consent to the Uptown Music Collective to use photos and videos (including live streams) of my child for publicity and promotional purposes. *
Questions or Comments?
Please list any questions you might have and they will be answered in the Admission Director's response.
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