Student Name *

First Name

Last Name

Student Age *

First Name

Last Name

Emergency Contact 1 *

First Name

Last Name

Phone *

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Emergency Contact 2 *

First Name

Last Name

Phone *

(###)

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Does the student have any food or environmental allergies or health issues that Jessica should be aware of? Please list below. *

(###)

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Photo/Video Release: Please check YES or NO. Jessica Schable Music Studio utilizes photos and videos of students in their marketing and publicity in local papers, flyers, posters, Facebook, YouTube and Instagram. The studio uses images of m minors with their first names, and no other identifiers. Students an/or their guardian may opt out of being featured with their image/name. *

YES- I give consent for Jessica Schable Music Studio to use images of my student in promotions

NO- I do not want my child's image used in any promotional materials