Superpower of the Song Enrollment Form

Small Group Piano Class Registration

At Superpower of the Song we provide high quality music instruction while cultivating creativity and inspiration that will last a lifetime. Have fun while exploring musical concepts such as pitch and rhythm, developing musical sensitivity, knowledge of keyboard geography, patterns on the keys, singing, playing songs, performance protocols and more!
Classes are held at Piedmont Center for the Arts, 801 Magnolia Avenue, East Wing, Piedmont, CA 94611

Thursdays: 4:00 - 4:45 pm

1st session: August 29th - October 3rd

2nd session: October 10th - November 21nd 2019

NO CLASS on HALLOWEEN, 10/31/19

3rd session: November 21st - December 19th 2019

NO CLASS on THANKSGIVING

www.superpowerofthesong.com
Student Information 1
First name *

First Name Last Name
Age as of 8/29/2019
Birthday

Month Day Year
Date Date Picker Icon
Grade in School - Fall 2019
School attending
Student Information 2
Name

First Name Last Name
Age as of 8/29/2019
Birthday

Month Day Year
Date Date Picker Icon
Grade in school
School attending
Address Information

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Extra Information
Home phone

Area Code Phone Number
Email
example@example.com

T-shirt measurements

	YS	YM	YL	XS	S	M	L	XL	XXL
	(6-8)	(10-12)	(14-16)
Length	20.875"	22.25"	23.37"	27"	28"	29"	30"	31"	32"
Width	15.25"	16.25"	17.25"	16.5"	18"	20"	22"	24"	26"

T-shirt size (see chart above)
In an emergency call first

First Name Last Name
Phone Number

Area Code Phone Number
The following person/s may not remove my child from the facility
Consent Information
Do you provide consent for the child's photograph to be released?

Yes No N?A
Medical Information
Insurance Covered?

Yes No Other
Insurance Company
Insurance Policy Number
Hospital Preferred
Hospital Phone

Area Code Phone Number
Doctor's Name
Doctor's Phone

Area Code Phone Number
Dentist's Name
Dentist's Phone

Area Code Phone Number
Allergy Information
Child allergic to food or other substances (If so, name foods or substances to be avoided and procedure to follow if reaction occurs)?

Yes No
Child's allergies and procedures to follow
Child allergic to any medications?

Yes No
Details
Does child have environmental allergies?

Yes No
Details
Medical Conditions
Does your child have asthma?

Yes No
If your child has Asthma, will your child have an inhaler at site?

Yes No N/A
Asthma details:
Does your child have an epi-pen on site:
Does your child wear glasses or contacts?
Does your child have Epilepsy/seizures?
Date of last seizure

Month Day Year
Date Date Picker Icon
Details
Has your child had chickenpox?
If yes, date

Month Day Year
Date Date Picker Icon
Does your child have frequent colds?
How many in the last year?
Does your child have Diabetes?
Details

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
Does your child have any special problems/fears?
Special problems/fears
Child have cerebral palsy/motor disorder?
Motor issue details
Physical conditions and precautions
Child have cognitive/learning disabilities?
Cognitive/Learning disability details:
Child have ADD/ADHD?
ADD/ADHD details:
Child have Autism Spectrum?
Autism Spectrum Disorder and details
Child have any behavioral Issues?
Behavior details:
Child have any disabilities or other conditions that may require special care?
Other condition details:
Child has been diagnosed with a communicable disease
Communicable disease details:
Support and Instructions
Does your child receive additional support services or one-on-one support during the school year?
Additional support details
I have reviewed the activities of the program and feel my child can participate without restrictions
If no, my child can participate with the following restrictions or accommodations:
Signs or symptoms to watch for
Does your child have any special needs/accommodations?
Specify triggers that may cause problems and steps the staff should follow in response
When to consider that the condition requires emergency medical care or reassessment
When to call parents regarding symptoms or failure to respond to prescribed treatment
Additional comments
Other special instructions
Immunization Information
Are your child's immunizations up to date?
For religious reasons this child should not be immunized
For personal conviction reasons this child should not be immunized
Guardian Information 1
Name

First Name Last Name
Relationship Type
Address same as new student

Address 1

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Address 2

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Area Code Phone Number
Work Phone

First Name Last Name
Cell Phone

Area Code Phone Number
Email
example@example.com
Would you like to Opt-Out of receiving email messages from Superpower of the Song?
Electronic signature
Typing your name here is your authorized signature
Guardian Information 2
Name

First Name Last Name
Relationship type
Address same as new student

Address 1

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Address 2

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home phone number

Area Code Phone Number
Work phone number

Area Code Phone Number
Cell phone number

Area Code Phone Number
Email
example@example.com
Electronic signature
Typing your name here is your authorized signature
Would you like to Opt-Out of receiving email messages?
Emergency Contact Information 1
Name

First Name Last Name
Relationship Type

Address 1

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Address 2

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home phone number

Area Code Phone Number
Work phone number

Area Code Phone Number
Cell phone number

Area Code Phone Number
Email
example@example.com
Emergency Contact 2
Name

First Name Last Name
Relationship type

Address 1

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Address 2

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email
example@example.com
I am signing my child/ren up for:
How did you find out about us?
Payment of $165 for 3rd session -due prior to class starting
Your registration will be complete and child's place reserved upon receipt of your enrollment fee for each session. If you wish to inquire about payment plan options please email Kadiekelly@superpowerofthesong.com
Thank you for supporting your chid as they discover and tap in to Superpower of the Song! We look forward to your next session of music with us!
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Small Group Piano Class Registration

Student Information 1

Student Information 2

Address Information

Extra Information

Consent Information

Medical Information

Allergy Information

Medical Conditions

Support and Instructions

Immunization Information

Guardian Information 1

Guardian Information 2

Emergency Contact Information 1

Emergency Contact 2