CAP Saturday Music Classes Application

*

READ CAREFULLY: This is a serious endeavor that requires attendance EVERY Saturday. Consider this carefully BEFORE applying. Student’s and parent’s digital signatures below and the submission of this application confirm that BOTH student and parent have read and understand this and that OVERALL schedules can accommodate a FULL commitment.

Student's Digital Signature*

First Last

Parent's or Guardian's Digital Signature*

First Last

Student's First Name*

Student's Middle Intitial

Student's Last Name*

Parent's or Guardian's First Name*

Parent's or Guardian's Middle Intitial

Parent's or Guardian's Last Name*

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Telephone*

Parent's or Guardian's Cell Phone

Student's Cell Phone

Parent's or Guardian's Email*

Enter Email Confirm Email

Student's Email*

Enter Email Confirm Email

How or from whom did you hear about this Program?*

Student's School*

School Music Teacher

School Music Teacher's Phone

School Music Teacher's Email

Enter Email Confirm Email

Grade in 2021-22 School Year*

Is the student enrolled in Breakthrough Miami on Saturdays?*

Yes
No

Indicate your Saturday Breakthrough Miami HOURS.*

Also, indicate your Saturday Breakthrough Miami LOCATION.*

List ANY other 9:30 a.m.-4:30 p.m. Saturday activities and times in which the student is/may be involved. NOTE: This may limit our ability to provide any or the best schedule for the student's CAP classes.*

Student's Birthday*

MM

DD

YYYY

Does the student receive free lunch at school?*

Yes (Proof of Waiver is required.)
No

Parent or Guardian: UPLOAD BELOW the Proof of Waiver showing that your child receives free lunch at school. ALL INFO REMAINS CONFIDENTIAL.*

Does the student have any disability of which we should be aware in order to best serve the student? ALL INFO REMAINS CONFIDENTIAL.*

Yes
No

Please describe the disability below.*

CAP Saturday Music Classes equals a $50 discounted cost each week and includes one 55-minute instrument lesson and music theory. Is the student in need of a scholarship (i.e., a weekly amount of $50 or less)?*

Yes (If yes, EACH parent or guardian is required to submit the most-recent Tax Form 1040 and two most-recent pay stubs.)
No

What amount, $0-$50, can the parent(s) or guardian(s) pay each week?*

Parents or Guardians: Please UPLOAD BELOW your most-recent Tax Form 1040 AND two most-recent pay stubs from EACH parent or guardian AND from whomever claims the student for tax purposes. BELOW ARE FOUR FILE BLOCKS. (If possible, combine all--tax forms and pay stubs--into one file, and upload to one, below FILE block.) ALL INFO REMAINS CONFIDENTIAL.*

File

IN THE BOX BELOW, briefly outline your need and provide helpful comments that support your need. All information is strictly confidential.

Please use this area to indicate any additional info. for scholarship consideration.*

Select the one instrument that the student would like to study:*

If the one instrument the student would like to study is not on the above list, please enter that instrument below.*

Does the student have daily access to his or her choice instrument for consistent weekly lessons and daily practice at home? (If piano, this refers to an actual piano, not a "keyboard.")*

Yes
No

Will the student have lessons on his or her choice instrument anywhere else other than CAP?*

Yes
No

Where else will the student study his or her choice instrument?

How long (i.e., years, weeks, or months) has the student had lessons on his or her choice instrument? (If new to the instrument, enter "0".)*

With whom has the student studied his or her choice instrument? (If new to the instrument, enter "N/A".)*

List all music classes and lessons that the student has had and for how long.*

Write up to five lines that tell why the student would like to participate in this program and what the student would like to do with music.*

PARENTS' NOTE: Students' success hinges on parents' encouragement and interest in their child's learning and personal growth. A commitment to consistent Saturday attendance is key to this.

Additional field trips (i.e. concerts and performances) will be a part of this program. Continuation in the music program is based on consistent, weekly attendance, behavior, and satisfactory growth within the program.

I give permission to use my child's name, photograph and/or performance recordings (including audio and/or video forms) in brochure, web, and other promotional materials.

Parent's or Guardian's Digital Signature*

First Last

Date*