Student's Name*

First Last

Age*

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!

Does the student have a disability?*

Yes
No

If yes, accommodations needed?

What school does the student attend?

What is the student's current grade?

What other music programs is the student involved in?

Does the student have a mobile device or computer with internet connection?*

Yes
No

*This program requires a mobile device or computer with internet connection

Student's Preferred Gender Pronoun*

He/Him
She/Her
They/Them
Prefer Not to Answer

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

Race*

Ethnicity?

Country of origin?

Parent Information

Parent/Guadian Name*

First Last

Relationship to Student*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone

Home Phone

Email*

Parent/Guardian Language Preference

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Relationship to Child*

Phone*

Phone 2

Household Demographics

Relationship Status

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

Any practicing Religion?

What is your Household Gross Income?

Female Head of Household

Number 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 agree to give the student permission to participate in a Zoom conference for this virtual music camp, I understand that a portion of these sessions will be simultaneously streamed via Facebook

Name

This field is for validation purposes and should be left unchanged.

Levitt Virtual Songwriting Camp

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