Plugged In Band Program · Media Scoring

Student Information

How did you hear about Plugged In?

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Other

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How did you hear about Plugged In?

Student Name

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First Name

Last Name

Preferred Name / Nickname

Gender

*

Preferred Pronouns

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Pronouns

*

Please indicate what your preferred pronouns are.

Student Birthdate

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mm/dd/yyyy

Student Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Student Email

Verify Email

Student Home Phone

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Student Mobile Phone

School Name

*

Current Grade

*

Enter grade number only

Parent Contact Information

Parent 1 Name (primary contact)

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First Name

Last Name

Parent 1 Primary Phone

*

Is parent 1 primary phone a cell or home phone?

*

Cell

Home

Parent 1 Email

*

Verify Email

*

Parent 1 Employer

Parent 2 Name

First Name

Last Name

Parent 2 Primary Phone

If different than parent 1

Is parent 2 primary phone a cell or home phone?

Cell

Home

Parent 2 Email

Verify Email

Parent 2 Employer

Emergency Contact Information

Whom should we contact in case of an emergency? If registering for the youth program, please provide an alternate contact to the student's parents.

Emergency Contact Name

*

First Name

Last Name

Emergency Contact Primary Phone

*

Provide the most reliable number for this emergency contact

In order for the student to have the best possible experience at Plugged In, we strongly encourage you to share information regarding medical conditions, disabilities, behavioral and emotional concerns, allergies, etc.

PLEASE CHECK ALL THAT APPLY - (Information regarding a student may be shared with the Plugged In Directors and their teacher, and will otherwise remain confidential.) .

Autism Spectrum Disorder (ASD)

Attention Deficit Disorder / Hyperactivity Disorder (ADD/ADHD)

Depression

Anxiety / Social Anxiety

Allergies

Physical Limitation

Other

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Please identify and describe the student's condition.

Would you like to be contacted by the Plugged In Inclusion Committee?

Plugged In is a fully inclusive program. The Plugged In Inclusion Committee acts as a resource for students/families that may need additional supports to ensure their best possible experience.

Yes

No

Would you like to be part of the Plugged In Inclusion Committee?

Yes

No

Please share any information that would be important for the band teacher to know in working with the student.

Ex: student excels in structured environment, student requires breaks, student is shy, etc.

Fall 2023 Session Showcase

Mark your calendar now!

Fall Session Showcase

January 12-14, 2024

Is the student interested in being part of the Plugged In volunteer team?

Yes

No

Student Volunteer Tasks

Please check all that apply

Volunteering in a band with a student with a disability

Volunteering in a band with younger students

Joining the Plugged In Youth Board

Are you (the parent) interested in volunteering at Plugged In?

Plugged In is always looking for skilled adult volunteers for various roles. If you would like to be contacted about volunteering at Plugged In select "yes" and our Volunteer Outreach Coordinator will contact you.

Yes

No

Parent Volunteer Tasks

Please check all that apply

Marketing (hanging up flyers, community emails, social media, etc.)

Performance Production (transporting, setting up, and breaking down equipment, live sound)

Plugged In Board of Directors

Plugged In Committee(s) (Facilities, Finance, Inclusion, Development, etc.)

Parent Volunteer Skills

Do you have a particular skill that you would like to volunteer? ex: graphic design, book keeping, event planning, etc.

Are you interested in volunteering at Plugged In

Plugged In is always looking for skilled adult volunteers for various roles. If you would like to be contacted about volunteering at Plugged In select "yes" and our Volunteer Outreach Coordinator will contact you.

Yes

No

Volunteer Tasks

Please check all that apply

Marketing (hanging up flyers, community emails, social media, etc.)

Performance Production (transporting, setting up, and breaking down equipment, live sound)

Plugged In Board of Directors

Plugged In Committee(s) (Facilities, Finance, Inclusion, Development, etc.)

Volunteer Skills

Do you have a particular skill that you would like to volunteer? ex: graphic design, book keeping, event planning, etc.

Scholarship

Plugged In's scholarship fund was created to meet the need of those students who are interested in participating in Plugged In, but whose family may not have the financial resources to pay full tuition. Plugged In's goal is to ensure music instruction and a welcoming community to all young musicians. To help determine a family's need for scholarship applicants must provide the requested financial documentation. Applicants are also able to share and factor in any extenuating circumstances that may effect their ability to pay tuition. Examples of extenuating circumstances can include but are not limited to, limited income, sudden death or abandonment of the primary provider, single parent households, etc. Applicants may be asked to provide additional documentation to illustrate their need to qualify such as recent pay stubs, letters of reference, etc. Plugged In is committed to ensuring all young musicians have access to programming.

I wish to apply for band class scholarship for the student.

*

Yes

No

Number of Family Members

How many people are in your immediate family?

Please enter your family's combined gross income

This is typically line 37 on your IRS tax form 1040.

Please provide us with a copy of your most recent years IRS form 1040.

.pdf and .jpg file types accept. Upload limited to 10MB. If you are unable to provide an electronic copy of your IRS 1040 form please contact Plugged In for support.

Please describe any extenuating circumstances that dramatically effect your listed gross income.

Examples of extenuating circumstances can include but are not limited to - limited income, sudden death or abandonment of the primary provider, single parent households, care of child with a disability or aging family members, etc.

Scholarship Sliding Scale

Please select your level of scholarship

*

Please choose the appropriate scholarship level for your family based on the Sliding Scale chart above. If you have described an extenuating circumstance above please select the scholarship level that best fits your circumstance. You will be contacted if Plugged In requires additional information regarding your choice of scholarship level. *If you wish to submit payment for any remaining tuition fee after scholarship using your credit/debit card please contact Plugged In for an electronic invoice.

Full Scholarship

Partial - $210 tuition payment

Partial - $350 tuition payment

Partial - $490 tuition payment

Partial - $630 tuition payment

Policy

To participate in Plugged In you must read, understand, and agree to the following policies. If you have questions regarding any of the following policies please contact Plugged In directly.

Read Release of Liability / Indemnity / Emergency Treatment Agreement

Read Media Release Agreement

Read Code of Conduct Agreement

Read Attendance Policy

The student and/or guardian have read and agree to the Release of Liability / Indemnity / Emergency Treatment Agreement

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Yes

The student and/or guardian have read and agree to the Media Release Agreement

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Yes

The student and/or guardian have read and agree to the Code of Conduct Policy

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Yes

The student and/or guardian agree to participate in a "new student meeting" prior to the start of the session.

*

If a student is under 18 years old a parent or guardian must attend the new student meeting.

Yes

Total Tuition Due - $0

Total Tuition Due - $210

Total Tuition Due - $350

Total Tuition Due - $490

Total Tuition Due - $630

Total Tuition Due - $770

Payment

Send your payment to:

Plugged In Band Program

40 Freeman Place.

Needham, MA 02492

Checks can be made out to Plugged In Band Program. Please include the student's full name in the memo section of your check.

Media Scoring - Fall 2023 (c)

Student Information

Parent Contact Information

Emergency Contact Information

Scholarship

Read Release of Liability / Indemnity / Emergency Treatment Agreement

Read Media Release Agreement

Read Code of Conduct Agreement

Read Attendance Policy