Plugged In Band Program · Creating Music with Coding Spring 2023 (c)

How did you hear about Plugged In?

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Other

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How did you hear about Plugged In?

Has the student participated in Plugged In programming before?

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Yes

No

Student Information

Student Name

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First Name

Last Name

Gender

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Preferred Pronouns

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Pronouns

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Please indicate the student's preferred pronouns.

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

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Current Grade

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Enter grade number only

Does the student have a family member participating in a Plugged In Spring 2023 music technology class?

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Yes

No

Parent Contact Information

Parent 1 Name (primary contact)

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First Name

Last Name

Parent 1 Primary Phone

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Is parent 1 primary phone a cell or home phone?

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Cell

Home

Parent 1 Email

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Verify Email

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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? Please provide an alternate contact to the student's parents.

Emergency Contact Name

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First Name

Last Name

Emergency Contact Primary Phone

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Provide the most reliable number for this emergency contact

Additional Information

What is the primary device the student will be using to participate in class?

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Other

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Student's Primary Device

Does the student have any experience with digital audio production?

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Digital audio production experience is not required.

What digital audio production tools (software/hardware) has the student used in the past?

What style of music does the student prefer most?

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Other

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What style of music does the student prefer most?

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 works with students/families that may need additional supports to ensure their best possible experience.

Yes

No

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

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

Showcase

Plugged In holds a benefit concert at the end of every program session. For our online programs, this event is a livestream showcase of student projects. In addition to presenting their projects and performances, the benefit concerts and showcases also give students a unique opportunity to give back to the community. Each benefit concert and showcase raises funds and awareness for a charity chosen by the session's students. The concerts and showcases show students they can make positive change in the lives of others by doing something they love, like creating music.

The Spring Session Benefit Concert and Showcase will be June 16-18, 2023.

Showcase Scheduling

We do not accept concert scheduling requests. All students must be able to perform/present when scheduled.

Would the student like to get information about joining our Youth Board?

Yes

No

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

Plugged In is always looking for skilled adult volunteers for various roles. If you are interested in volunteering for Plugged In please select "yes" and our Volunteer Outreach Coordinator will contact you.

Yes

No

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 scholarship for the student.

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Yes

No

Number of Family Members

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How many people are in your immediate family?

Please enter your family's combined gross income

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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.

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.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

Scholarship Sliding Scale 1.23

Scholarship Sliding Scale

Plugged In Band Class Scholarship Sliding Scale 1.23 - Family Member Participating.jpg

Please select your level of scholarship.

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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 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

Please select your level of scholarship

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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 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 - $160 (w/ family discount)

Partial - $300 (w/ family discount)

Partial - $440 (w/ family discount)

Partial - $590 (w/ family discount)

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 Agreement.

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Yes

The student and/or guardian have read and agree to the Attendance Policy.

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Yes

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

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

Yes

Total Tuition Due - $0

Total Tuition Due - $160 (w/family discount)

Total Tuition Due - $210

Total Tuition Due - $300 (w/family discount)

Total Tuition Due - $350

Total Tuition Due - $440 (w/family discount)

Total Tuition Due - $490

Total Tuition Due - $590 (w/family discount)

Total Tuition Due - $630

Total Tuition Due - $770

Total Tuition Due - $720 (w/family discount)

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.