subject_line
MODE MUSIC AND PERFORMING ARTS Account Registration and Contract
Mode Music and Performing Arts / 3801 Delridge Way SW / Seattle WA 98106 / modemusicandperformingarts.org
STUDENT INFORMATION
First Name
*
Last Name
*
Date of Birth
*
+
Gender
*
Male
Female
Non-binary
Grade in 2019-2020
*
0-4 years
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Email address (if applicable)
Does the student have any medical, learning, behavioral or other special considerations / circumstances of which the school should be aware? (Please explain): *
*
PRIMARY CONTACT INFORMATION
Relationship to student
*
Mother
Father
Guardian
Other (please explain)
Other (please explain)
Contact #1 First Name
*
Contact #1 Last Name
*
Cell Phone Number
*
Email Address (for invoicing)
*
Confirm Email Address
*
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
SECONDARY CONTACT INFORMATION
Contact #2 First Name
Contact #2 Last Name
Cell Phone Number
Email Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
EMERGENCY CONTACT INFORMATION
In case of an emergency, who should we contact first?
First Name
*
Last Name
*
Cell Phone Number
*
Email Address
*