4th and 5th Grade

Strings Club Registration

Student Info

Student Name(Required)

First Last

Nickname/Preferred first name(Required)

Date of Birth(Required)

Pronouns(Required)

Grade as of Spring 2022(Required)

Presently enrolled at (school name):(Required)

T-shirt size(Required)

Student's Music Experience

Student's instrument of choice:(Required)

Does the student have any prior experience with a string instrument?(Required)

Parent/Guardian Info

Please enter info for multiple parents/guardians if you'd like:

Parent/Guardian Name(Required)

First Last

Relationship to student:(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Name

First Last

Relationship to student:

Phone

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Names of other adult persons to whom your child may be released:(Required)

If you wish to apply for a scholarship, please tell us a specific amount of scholarship money you will need from SSA for your child to participate in Strings Club:

Health Information

Allergies(Required)

Please list the student's food, drug, or environmental allergies, if any. Type 'none' if none.

Medications(Required)

Will the student need to take any medications while at Strings Club Programming, or will the student need to carry any medications with them during Strings Club Programming (such as an epipen for bee stings)? Please explain. Type 'no' if the answer to either question is no.

Did the student experience any significant physical health issues or events in the last year?(Required)

Should the student's physical activity be restricted for any reason?(Required)

Does the student have any past or current mental health issues we should be aware of?(Required)

Does the student have any social/emotional issues we should be aware of in relation to other students in Strings Club?(Required)

Does the student have any coping strategies we can use to help during times of emotional distress?(Required)

Is there anything else we should know about the student's health?(Required)

Is there anything else we should know that would help us make Strings Club the most positive possible experience for the student?(Required)

Insurance

Is the student covered by medical insurance?(Required)

If the student is NOT covered by medical insurance, please type 'none' in all the following prompts.

Name of Insurance Company(Required)

Insurance Company Phone Number(Required)

Group #(Required)

Policy/Member #(Required)

Name of Policy Holder(Required)

Please upload a picture of your insurance card:

Max. file size: 10 MB.

Emergency Contact

Please list an adult who was NOT listed as a parent/guardian. This should be someone we can contact in the event of an emergency, in case we cannot get a hold of any parents/guardians listed above.

Name

First Last

Relationship to student:

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorizations

Parent or guardian, please electronically sign each authorization by typing your full name in each prompt.

Photo/Video Release, please type full name:(Required)

I hereby authorize the use of any photos or video taken of my child during Strings Club to be used for advertising purposes in posters, brochures, promotional videos, and social media.

Health Information Signature, please type full name:(Required)

I certify that the health information in my child's registration form is true to the best of my knowledge.

Health Care Authorization Statement, please type full name:(Required)

I hereby give my permission to Superior String Alliance to provide routine, nonsurgical medical care, and to secure emergency medical, surgical, and dental treatment for my child in the event of an emergency while she/he/they is/are attending SSA Programming.

Strings Club Handbook Statement, please type full name:(Required)

I certify that both my child and I, the parent/guardian, have read the SSA Strings Club Handbook (which includes the Student Code of Conduct) found on SSA's website at https://superiorstringalliance.org/strings-club/

Strings Club Tuition Payment

Tuition is due in full by May 17th. If you are applying for a scholarship you will receive an email from SSA within one business day of submitting your registration form letting you know the scholarship amount we are able to give you. We would prefer if you are able to mail a check made out to 'Superior String Alliance' to our address at P.O. Box 52, Marquette, MI 49855. If you need to pay tuition via debit or credit card, please navigate to SSA's donate page and you can pay online via our Paypal donation page. Please send us an email at admin@superiorstringalliance.org letting us know that you paid online and the name of your child.