2021-22 Upbeat Middle School/High School Semi-Private Lessons

Student Name (required)

School Attended

Grade

Instrument Choice
ViolinViolaCelloDouble Bass

Primary Contact Name

Home Address (Street, City, State, Zip)

Home Phone

Cell Phone

Email Address

Lessons or performances might be photographed or videotaped with the intent to publish on our website, facebook page or utilize in grant applications.
Permission to use photograph YesPermission to use photograph No

Permission to use child's name with photography.
Permission to use name YesPermission to use name No

Allergies (Please list all allergies, select 'no' if student has no allergies)
YesNo

I HEREBY AUTHORIZE ANY LICENSED PHYSICIAN, HOSPITAL, CLINIC OR OTHER MEDICAL FACILITY TO HOSPITALIZE AND SECURE PROPER TREATMENT FOR MY CHILD NAMED ABOVE

Please enter your Health Insurance Provider

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