Plugged In Band Program · Intro to Band Class - Mini Music Making August 2024 (c)

Are you registering for the Youth or Adult Program *

While flexible Plugged In's Youth Band Class is typically appropriate for students ages 8-19 and our Adult Band Class is typically appropriate for those 20 years or older.

How did you hear about Plugged In? *

Other *

How did you hear about Plugged In?

Student Information

Student Name *

First Name

Last Name

Preferred Name / Nickname

Gender *

Preferred Pronouns *

Pronouns

Please indicate the student's preferred pronouns below.

Student Birthdate *

mm/dd/yyyy

Student Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Student Email

Verify Email

Student Home Phone *

Student Mobile Phone

School Name *

Current Grade *

Enter grade number only.

Parent Contact Information

Parent 1 Name (primary contact) *

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

Band Placement Information

Student's Primary Instrument *

Other *

Student's Primary Instrument

What additional instrument(s) is the student interested in playing? *

Check all that apply, select at least one

Guitar

Bass

Drums

Keyboard

Vocals

Other

Other *

What additional instrument(s) is the student interested in playing?

How long has the student been playing their primary instrument? *

Is the student self-taught or have they had formal lessons? *

Is the student open to singing in their band? *

Yes

No

What style of music does the student prefer most? *

Other *

What style of music does the student prefer most?

What are some of the student's favorite bands? *

Are there other Plugged In students with whom the student would like to be in a band?

Provide first and last name. Separate students with a comma.

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 teachers, and will otherwise remain confidential.) .

Autism Spectrum Disorder (ASD)

Attention Deficit Disorder / Hyperactivity Disorder (ADD/ADHD)

Depression

Anxiety / Social Anxiety

Allergies

Physical Limitation

Other

Other *

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 additional information that would help with band placement.

Ex: prefers to be with older students, prefers to be with low-key performers, etc.

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.

Band Class Scheduling

Please check which times you are available for.

Band Class Times *

Please choose all options that work for your schedule to ensure the best band class placement

12:30p-2:00p

6:00p-7:30p

Participation - More Than Music

Our community thrives on mutual support and involvement in and out of band class. It is common for students to participate in more than one band, volunteer to help in addiitonals bands, support other programmatic pieces of Plugged In, etc. There are many ways that students and families can get more involved in Plugged In, all of which bring our community closer together.

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 adults volunteer 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 adults volunteer 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 Information

We are committed to offering programming that is accessible to those for whom cost is a participation barrier through partial and full scholarships, as well as the Card to Culture Program.

I wish to apply for scholarship for the student. *

Yes

No

Check Payment

If you are not applying for scholarship, check payments can be mailed or delivered to 40 Freeman Place, Needham, MA 02492.

Intro to Band Class Tuition Due - $220

Card to Culture Program

We are proud to participate in Mass Cultural Council's Card to Culture program making cultural programming accessible to those for whom cost is a participation barrier. EBT, WIC, and ConnectorCare cardholders can receive a partial (minimum 50% discount) or full scholarship on all program pieces, including private lessons, band class, and summer camp.

Card to Culture *

I am an EBT, WIC or ConnectorCare cardholder.

Yes

No

Card Information *

Please select which card. Thank you.

EBT

WIC

ConnectorCare

Please email info@pluggedinband.org and let us know if you require partial or full scholarship. Thank you.

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.

The student and/or guardian has read and agreed to the Media Release Agreement *

Yes

The student and/or guardian has read and agreed to the Code of Conduct Policy *

Yes

The student and/or guardian has read and agreed to the Band Configuration Policy *

Yes

Intro to Band Class - Mini Music Making August 2024 (c)

Student Information

Parent Contact Information

Emergency Contact Information

Band Placement Information

Read Release of Liability / Indemnity / Emergency Treatment Agreement

Read Media Release Agreement

Read Code of Conduct Agreement

Read Band Configuration Policy

Read Attendance Policy