Note: * are required fields

I. Biographical Information for Student

Last Name*
First Name*
Street Address*
City*
State*
Zip Code*
Home Phone Number (ex. 123-456-7890)
Student Cell Phone Number
May we text this number?	Yes No
Email Address
School Attending
Year in School
Date of Birth*

II. Parent Information

The following following information is needed for students who are 18 years or younger. If the student is 18 years or older, please skip to next section.

Parent Name(s)
Preferred Phone
Secondary Phone
Parent Email (If they would like information concerning events, recitals, etc.)

III. Activity Information

What type of lessons are you seeking?*
T-Shirt Size
Would you like financial aid information?	Yes No

IV. Fees

The CMS administrator will contact the applicant about lesson fees prior to the first lesson in order to confirm fees and payment arrangements.

V. Photo and Video Release*

It is vital that the CMS keeps updated records of events and an active website which may contain student's photos. Names of students will never be identified.

I GIVE permission to the Community Music School at Southwestern College to use my/my child's photograph for the school's promotional material.

I DO NOT give permission to the Community Music School at Southwestern College to use my/my child's photograph for the school's promotional material.

Southwestern College is committed to a policy of nondiscrimination on the basis of race, color, gender, age, religion, national origin, handicap, or other nonmerit reasons, in admissions, educational programs or activities, and employment, all as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries, including those concerning Title IX of the Education Amendments of 1972 and Section 504 of the Rehabilitation Act of 1973, has been delegated to the vice president for business affairs, Christy Administration Building, Southwestern College, 100 College Street, Winfield, KS 67156-2499, (620) 229-6000. Southwestern College complies with the Crime Awareness and Campus Security Act of 1990. The yearly report is available from the dean of students upon request. Race and ethnic origin information is voluntary and will not be used in a discriminatory manner.