Music Lab Enrollment Form 2022/2023
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Email *
Student Information:
First Name: *
Last Name: *
Date of Birth: *
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Gender: *
Name of School/School Program: *
Type of School Program: *
Grade Level: *
Parent/Guardian Name: *
Relationship to Student: *
Street Address: *
City/County: *
Zip Code: *
Parent Email: *
Student Email:
Home Phone: *
Work Number: *
Parent Cell Phone: *
Student Cell Phone:
Please select your enrollment type: *
Part of our mission is to ensure The Music Lab is accessible to all students regardless of their financial situation. We have tried to set tuition at a rate that is affordable for many, but we understand everyone has a different situation.  For an annual membership fee of $300 or semester fee of $175, teens in grades 6-12 can attend the Music Lab at Jefferson Center’s Music Lab program to learn music production & recording, performance skills and music business. If this tuition is not affordable for you, please email jharman@jeffcenter.org and state what rate is possible for you.  Our priority is that students have access to the resources at Jefferson Center.
Demographic Information
Please note: Providing this information is optional. It does, however, help the Music Lab at Jefferson Center acquire grant funding for the program.
Race:
Clear selection
Is English a second language?
Clear selection
Are other languages spoken in the home?
Clear selection
If so please list them:
Media Release
I hereby grant Jefferson Center the right to use, reproduce, distribute and/or transmit photographs, videotape and/or recordings of my child, in whole and in part, and permit the use of their name in conjunction with these materials. I acknowledge that such photographs, videotape and/or recordings of me and any associated materials, printed, electronic, or other may become part of copyrighted materials that Jefferson Center may distribute to others in furtherance of its educational mission. If you prefer to opt out of the media release, please speak with Jordan Harman, Education Director, directly at 540-685-2309.
Do you agree to these terms? *
Music Lab Policies

1. You must be in 6th through 12th grade and currently enrolled in school or home schooled (certified by parent) to enroll at the Music Lab. (*occasionally members outside these ages may be accepted, please contact Jordan Harman directly to inquire about special memberships) 

2. Profanity, racial slurs, or references to sex, drugs and/or violence are strictly prohibited. Clean and appropriate language must be used at all times. This applies to both recordings and member conduct while at the Music Lab. 

3. The possession, use, or influence of drugs, alcohol, or tobacco products are strictly prohibited and will result in immediate suspension or expulsion. 

4. Violence, vandalism, assault, or any other criminal behavior, including the possession of weapons, is strictly prohibited and will result in immediate suspension or expulsion. 

5. Disruptive or disrespectful behavior is not allowed anywhere inside or on the property of Jefferson Center. 

6. Members are required to respect all equipment (hardware, electronic, etc.) within the Music Lab. It is a privilege, not a right, to have access to the Music Lab equipment. Therefore any misuse of the Music Lab equipment could result in immediate suspension or expulsion. This includes, but is not limited to viewing or downloading inappropriate material on the Music Lab computers or destructive treatment of music/recording equipment. 

7. Loitering is strictly prohibited outside or near Jefferson Center or in the surrounding neighborhood. 

8. Members are not allowed to access other rooms or offices in Jefferson Center other than restrooms and 
the rooms/studios in Suite 325, specifically the Music Lab. 

9. Food is NOT allowed inside any room or studio within the Music Lab. Drinks may be consumed in the 
lobby. 

10. Members must keep their respective workstation area/room clean and free from clutter. 

11. Public or inappropriate displays of affection are strictly prohibited. 

12. Friends or guests that are not Music Lab members must be approved in writing by the director at least 48 
hours prior to their arrival. Any friend or guest is limited to three total visits per semester before either 
being required to become a member and/or attend orientation. 

13. Maximum occupancy limits for each room will be strictly enforced. 

14. Members who do not attend school are not allowed to come to the Music Lab for that day. Staff members may perform random attendance checks. 


Failure to abide by Music Lab policies may result in me being excluded from performances and/or recordings, suspension, and/or expulsion. These consequences are determined by the director per incident. I have read and understand the Music Lab Expectations and Policies. I agree to support the staff of the Music Lab in enforcing these expectations and policies. I understand that I, or my child, may be removed from the program for infractions.

Do you and your student agree to these terms? *
Emergency/Medical Information
First Contact Name: *
First Contact Number: *
First Contact Relationship to Student: *
Second Contact Name: *
Second Contact Number: *
Second Contact Relationship to Student: *
Please list any medical conditions, allergies, or other concerns of which we should be aware:
Musical Information
What are you favorites types of music? *
Required
List favorite artists/performers: *
How did you hear about the Music Lab? *
Do you play an instrument(s)? *
If so, please list the instrument and how long you have played below:
Check the Music Lab services that interest you: *
Required
List the top two things you would like to gain through the Music Lab: *
Thank you!
We are very excited to work with you soon!
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