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Online Songwriting Workshop Registration (February 15/16/17) (c)
Student Information
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How did you hear about Plugged In?
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First Name
Last Name
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mm/dd/yyyy
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code

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Enter grade number only
Parent Contact Information
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First Name
Last Name
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Emergency Contact Information
If the student's parents are unreachable during an emergency whom should we contact?
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First Name
Last Name
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Provide the most reliable number for this emergency contact
Musical Information
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Additional Information
PLEASE CHECK ALL THAT APPLY - (Information regarding your child will be shared with the Plugged In Directors and your child’s band teacher, and will otherwise remain confidential.) .
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Ex: student excels in structured environment, student requires breaks, student is shy, 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 may not have the financial resources to pay full tuition. Plugged In's goals is to ensure music instruction and a welcoming community to all our students. To help determine the need for scholarship applicants must provide the requested financial documentation. Applicants are also able to shar 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 musicians have access to programming.

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How many people are in your immediate family?
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This is typically line 37 on your IRS tax form 1040.
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.pdf and .jpg file type accepted. Upload limit 10MB. If you are unable to provide an electronic copy of your IRS 1040 form please contact Plugged In for support.

Examples of extenuating circumstances can include, but are not limited to, 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

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Please choose the appropriate scholarship level for your family based on the sliding scale chart above. If you have described an extenuating circumstance 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 a credit/debit card please contact Plugged In for an electronic invoice. Otherwise any remaining tuition can be paid via check (mailing address is at the end of this form)
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 COVID-19 Waiver

Read Release of Liability / Indemnity / Emergency Treatment Agreement

Read Media Release Agreement

Read Code of Conduct Agreement

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Total Tuition Due

$0 - Full Scholarship

Total Tuition Due

$35 - Partial Scholarship

Total Tuition Due

$70 - Partial Scholarship

Total Tuition Due

$105 - Partial Scholarship

Total Tuition Due

$140 - Partial Scholarship

Total Tuition Due

$175

Payment

Send your payment to:

Plugged In Band Program

40 Freeman Place.

Needham, MA 02492

 

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