Plugged In Band Program · Music That Matters Summer Day Camp 2023(c)

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?

Which Summer Session is the student attending?

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Student Name

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First Name

Last Name

Preferred Name / Nickname

Gender

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Preferred Pronouns

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Pronouns

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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

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Current Grade

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Enter grade number only

Does the student have a family member participating in Music That Matters Summer Day Camp 2022?

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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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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

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

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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

Band Placement Information

Student's Primary Instrument

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Other

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Student's Primary instrument

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

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Check all that apply

None

Guitar

Bass

Drums

Keyboard

Vocals

Other

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

How long has the student been playing their primary instrument?

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

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Is the student open to singing in their band?

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Yes

No

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?

What are some of the student's favorite bands?

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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, special needs, 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 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.

Benefit Concerts

Plugged In holds a benefit concert at the end of every session. The benefit concert acts as a recital where students perform the sets they’ve been learning for an audience. In addition to the performance the benefit concert also gives students a unique opportunity to give back to the community. Each benefit concert raises funds and awareness for a charity chosen by the students. The concert shows students they can make positive change in the lives of others by doing something they love, like playing music.

Mark your calendars now!

Music That Matters Session 1 Benefit Concert: July 21, 2023

Music That Matters Session 2 Benefit Concert: August 4, 2023

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

Parent volunteers provide support in all areas of Plugged In and are crucial to our continued success. Opportunities include joining our Board of Directors or sub-committees, helping with performance set-up and breakdown, marketing, and more.

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, event planning, etc.?

I'd like to be contacted about private instruction at Plugged In.

For more information about private instruction visit www.pluggedinband.org/programs/private-lessons

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 band class 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.

*

.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

Plugged In Scholarship Sliding Scale SU20 Summer Camp 4-Week.jpg

Scholarship Sliding Scale Copy

Plugged In Scholarship Sliding Scale SU20 Summer Camp 8-Week.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 - $280 in tuition payment

Partial - $560 in tuition payment

Partial - $840 in tuition payment

Partial - $1120 in 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 - $560 in tuition payment

Partial - $1120 in tuition payment

Partial - $1680 in tuition payment

Partial - $2240 in 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 Band Configuration Policy

Read Attendance Policy

Read Concert Scheduling Policy

Read New Student Meeting Policy (new students only)

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

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Yes

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

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Yes

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

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Yes

The student and guardian have read and agree to the Band Configuration Policy

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Yes

The student and guardian have read and agree to the Concert Scheduling Policy

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IMPORTANT - We have changed our concert scheduling policy! Please review the new policy before completing your registration.

Yes

The student and guardian have read and agree to the New Student Meeting Policy

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Reminder: Parent or guardian must attend the new student meeting.

Yes

Total Tuition Due - $0

Total Tuition Due - $280

Total Tuition Due - $560

Total Tuition Due - $1120

Total Tuition Due - $840

Total Tuition Due - $1680

Total Tuition Due - $1120

Total Tuition Due - $2240

Total Tuition Due - $1400

Total Tuition Due - $2800

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.