Thank you for your interest in the Rebel Song Academy. Our 2021 Spring/Winter session is full. If you're still interested in being part of the RSA community, join us every Tuesday night for RSA Live! Sign up at artasmentorship.org/rsalive!

Thanks for your interest in the Rebel Song Academy! Please fill out the following application to the best of your abilities.

This section is for students.

Applicant Name*

First Last

Age*

Phone Number

Email

Tell us about yourself as a musician/songwriter*

Who are some of your favorite musicians/bands/artists?

If you could master 3 different music-related skills, what would they be? (Examples: vocal performance, shredding on guitar, studio production)

What're you most interested in learning with RSA?

How do you connect with other artists? (Are you involved in any other social music platforms?)

Which virtual learning platforms are you familiar with? (Check all that apply)

Links to your music*

What other music programs is the student involved in?

Do you have a disability?*

Yes
No

If yes, accommodations needed?

What school do you attend?

What is your current grade?

Do you have a mobile device or computer with internet connection?*

Yes
No

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

This section is for parents/guardians.

Parent/Guadian Name*

First Last

Relationship to Student*

Art as Mentorship is committed to serving communities that have been routinely marginalized in the U.S. Because of this, we are very interested in learning more about the families we serve. Please use the following space to share some of what makes your family unique.

Race*

Ethnicity?

Country of origin?

Annual Household Income*

$0-$20,000
$20,001-$50,000
$50,001-$100,000
$100,000+

*Financial information is confidential and is for grant reporting purposes only.

Address

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

Mobile Phone

Home Phone

Email*

Language Preference

Relationship Status

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

How did you hear about this program?

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Relationship to Child*

Phone*

Phone 2

*

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 program, I understand that a portion of these sessions may be recorded for grant reporting and training purposes.

Thanks for completing your RSA application! One of our mentors will be in touch with you to have a brief interview with you and answer any questions you may have.

Name

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

Rebel Song Academy Application

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