Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Race / Ethnicity

Check all that apply

Asian

Indigenous American or Native Alaskan

Black or African American

Native Hawaiian or Other Pacific Islander

White

Latino

Other

Primary Languages Spoken

Check all that apply

English

Frainçaise

Portuguese

Arabic

Lingala

Kirundi

Español

Other

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary / Home Phone *

Country

(###)

###

####

Cell / Work Phone

Country

(###)

###

####

Preferred Instrument

Violin

Viola

Cello

Parent's Statement of Commitment *

Please check and sign

I would like my child to apply to the After-School Strings class. I have read and understand the After-School Strings description. I also understand that if accepted I will keep Palaver updated with any changes in the above information.

Signed Date of Application Form *

MM

DD

YYYY

Between Palaver Strings and Participating After-School Strings Students and Families

Student Name

First Name

Last Name

Photographs, Recordings, Video and Film Images

After-School Strings student performances and/or classes may be photographed, filmed, videotaped, and/or recorded. Palaver Strings has the students and families’ permission to use all images and sound recordings for publicity and to describe and illustrate the program to the public, print & online media, and funding organizations.

I understand and agree with the policy outlined in the above paragraph. *

Yes, I understand and agree with the policy outlined in the above paragraph.

No, I prefer to opt out of the media release.

If you selected "No" above...

...please tell us why in a few short words.

*

Signed Date of Release Form *

MM

DD

YYYY