Ignition Camp Sign-up - Art as Mentorship

Student First Name*

Student Last Name*

Student Age*

Student Phone Number

This will be used exclusively to coordinate class schedules, potential field trips and performance opportunities and will not be shared with anyone outside our immediate team.

Student Email Address

This will be used exclusively to coordinate class schedules, potential field trips and performance opportunities and will not be shared with anyone outside our immediate team.

Any Prior Musical Experience?

None, just starting out!
Some experience with musical instruments or singing
Lots of experience with musical instruments or singing
Seasoned performer

*No experience is necessary!

What instrument(s) do you play, if any?

*Vocals are an instrument, too!

Describe your musical experience, if you have any.

Have you ever or are you currently taking music lessons?

Yes
No

What other music programs is the student involved in?

Does the student have a disability?

Yes
No

If you answered "Yes" on the previous question, please describe the disability below.

Student's current school grade

Student's preferred gender pronouns

*Personal info about race/gender/ethnicity are for grant reporting purposes only and will not be shared.

Race

Black, non-Hispanic/Latino
White, non-Hispanic/Latino
White, Hispanic/Latino
Black, Hispanic/Latino
Native/Indigenous
Asian/Pacific Islander
Prefer not to answer

*Personal info about race/gender/ethnicity are for grant reporting purposes only and will not be shared

Country of Origin

Parent/Guardian Information

Parent/Guardian Full Name*

Relationship to Student

Street Address

Address 2

City

ZIP/ Postal Code

State/ Province/ Region

Country

Parent/Guardian Phone Number*

Parent/Guardian Email*

Parent/ Guardian Language Preference

Emergency Contact Name*

Emergency Contact Relationship to Child

Emergency Contact Phone*

Preferred Contact Method (check all that apply)
Preferred Contact Method (check all that apply)
Parent Email
Parent Phone
Student Email
Student Phone

Demographic Information

Relationship Status

Single

Married

Domestic Partnership

Other

Any Practicing Religion?

What is your household gross income?

*Personal household information is for grant reporting purposes only and will not be shared.

Female head of household?

Number living in household

How did you hear about this program

I confirm the truthfulness of the information provided in this form. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to Art As Mentorship's Terms of Acceptance.*
I confirm the truthfulness of the information provided in this form. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to Art As Mentorship's Terms of Acceptance.
Confirm

Media Release*
I hereby authorize Art as Mentorship and those acting pursuant to its authority to: (1) Record my or my child's image, likeness, and/or voice on a photographic, video, audio, digital, electronic, or any other medium; (2) Use, reproduce, modify, exhibit and/or distribute any such recording, in whole or in part, in any manner or medium now known or hereafter developed (including without limitation, print publications, email, internet, social media, television) for any purpose that Art as Mentorship may deem appropriate, including without limitation promotional or advertising efforts; and (3) Use my name and biographical material in connection with any such recordings or uses. I hereby waive the right to inspect or approve any such recordings and uses . I understand that Art as Mentorship will be the owner of all such recordings and uses. I hereby release and hold harmless Art as Mentorship from liability for any violation of any personal or proprietary right I may have in connection with all such recordings and uses. I have read and fully understand the terms of this consent and release.
Confirm

We ask each family we serve to contribute to the organization by becoming a sustaining "Band-Aid" member for as little as $10 per month. Donate at artasmentorshipkc.kindful.com

Any Dietary Restrictions?

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