Name of Applicant *

First Name

Last Name

Physical Address *

(no PO boxes)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

I am applying for... *

(Check ALL that apply)

INDIVIDUAL Lessons (RiverCity Rock Star Academy)

GROUP Lessons (RiverCity Rock Star Academy)

Program/Camp (RiverCity Rock Star Academy)

Other Community Music Instructor

I am... *

Under 18

Over 18

Parent/Guardian Name (if under 18)

First Name

Last Name

Parent/Guardian Phone (if under 18)

(###)

###

####

Best Time of Day to Call

Hour

Minute

Second

AM PM

Please indicate which ONE of the following you will send to info@salemmusicinitiative.org as proof of income:

Child is receiving services through ODHS Child Welfare (documentation waved)

A qualifying letter of child's enrollment in Federal Free/Reduced Lunch Programs

Copies of paystubs for the past 2 months (if under 18, include paystubs for all supporting parents)

The first two pages of last year’s IRS 1040 tax return with SSN and DOB blocked out

Signature Date *

MM

DD

YYYY