Música Franklin Registration Summer 2023--Turners Falls New Students

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PLEASE NOTE: On successful submission of this form you will see an automatic message that says, "Your response has been recorded." If you do not see this message, please scroll through for required fields you may have missed and try again. This form is for the confidential administrative records of Música 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 Música Franklin programs.

The Turners Falls summer program will run Mon-Thurs 1:00-3:00 July 5-Aug 3 (no class July 3rd or 4th) at Sheffield Elementary School. Students will be split into two groups that meet from 1:00-2:00 or 2:00-3:00. When they are not participating in Música Franklin, they will be in the Sheffield Elementary School summer program. Recess and lunch are available from noon until 1:00. Please contact info@musicafranklin.org or 413-475-6681 with any questions. This program is open to students entering grades 2 through 6.

Student Name *

Grade Level (as of Fall 2023) *

Birth Date: *

YYYY

Gender *

Male

Female

Non-Binary

T-shirt Size: *

Youth X-Small

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult X-Large

Adult 2X-Large

Musical Experience other than Música Franklin, if any: *

Please list any known allergies, food sensitivities, or dietary restrictions

Additional Children: Please list name, grade, gender, birthdate, allergies/food sensitivities, t-shirt size, and musical experience for any additional children from the same household who are enrolling.

Are there any weeks that your family will be away? Please tell us when.

Is your child attending ESY?

Yes

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If we need to incorporate virtual learning, do you have access to a zoom-compatible device and internet connection for your child to participate?
*

Yes, I have both

I have internet but need a device for my child

I have a device but need help with internet connection or data

I need help with a device AND with internet connection

Parent/Guardian 1 Name *

Parent/Guardian 1 Address *

Parent/Guardian 1 Town *

Parent/Guardian 1 Zip Code *

Parent/Guardian 1 Primary Phone (10 digits) *

Can this phone receive texts? *

yes

Parent/Guardian 1 Work Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 1 Other Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 1 Email (if no email, write "none") *

Parent/Guardian Preferred Contact Method *

Parent/Guardian 2 Name

Parent/Guardian 2 Address

Parent/Guardian 2 Town

Parent/Guardian 2 Zip Code

Parent/Guardian 2 Home Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 2 Work Phone

Can this phone receive texts?

yes

Clear selection

Parent/Caregiver 2 Other Phone

Can this phone receive texts?

yes

Clear selection

Parent/Guardian 2 Email

Parent/Guardian 2 Preferred Contact Method

Emergency Contact if we are unable to reach you--Full Name *

Emergency Contact--Phone *

Authorized pick-up: list all individuals authorized to pick your child(ren) up from Música Franklin programs. Please list FULL NAME and PHONE. Your child will ONLY be released to a parent/guardian listed on this form or those listed below. *

Photo and Video Release: By checking below, I give permission for my child to appear in photos and videos taken by Música Franklin, or a person authorized by Música Franklin. We will never identify students by their full name. *

I DO give permission for my child to appear in public photos and videos. This may include Música Franklin's e-newsletters, web site, and promotional materials, local newspapers, community television, social media, and more.

I DO NOT give permission for my child to appear in any public photos or videos

Confidential Portion: The following questions are 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 cooperation in providing this information is very much appreciated.

Student Ethnicity (please check all that apply)

Hispanic/Latino/Latina

Black/African American

American Indian or Native Alaskan

Native Hawaiian or Pacific Islander

Asian

White

Prefer to Not Say

Primary Language Spoken at Home

Household Size:

CONFIDENTIAL: The following question is important for our records and for the funding Música Franklin receives. The answers you provide are completely confidential and will never be used except as anonymous, aggregated statistics. Your cooperation in providing this information is very much appreciated.

Is your child diagnosed with a physical, mental or learning disability or have an IEP at school?

Yes

Prefer to Not Say

Clear selection

Does your family qualify for (please check all that apply):

SNAP

free/reduced school lunch

Medicaid

Health care premium assistance

CONFIDENTIAL: The following question is important for our records and for the funding Música Franklin receives. The answers you provide are completely confidential and will never be used except as anonymous, aggregated statistics. Your response is optional. Your cooperation in providing this information is very much appreciated.

Please list your total annual household income:

I have read and agree with the following Program Requirements: *

I understand that Música Franklin will adhere to all COVID-19 safety precautions and agree to have my child wear a secure-fitting face mask that covers nose and mouth when asked while participating in Música Franklin programs during the pandemic.

I understand that my child may not participate if they have had a fever, sore throat, cough, or other COVID-like symptoms in the previous 3 days, have had known contact with a person testing positive for COVID-19 within the past 14 days, or have traveled to a non-exempt region outside the state within the past 14 days. I agree to keep my child home if s/he is not feeling well.

I understand the program is in flux and subject to change due to the unique circumstances of COVID-19. Música Franklin will endeavor to keep families apprised of any changes in a timely manner.

I understand that there is some risk associated with any in-person activities during the pandemic regardless of precautions.

I agree to assume full responsibility for my child and hereby release Música Franklin and its representatives from any and all liability associated with my child's participation in the program.

I understand that Música Franklin does not employ medical staff. If a child requires emergency medical care during the program, we will call 911.

Required

By typing/signing my name below, I agree to all the above terms and conditions. *

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