TINY MODES REGISTRATION FORM

Mode Music and Performing Arts
3801 Delridge Way SW
Seattle WA 98106
http://www.modemusicandperformingarts.org

Tiny Modes are our group classes for kiddos ages 0-4 years. We use both original tunes and the music of Caspar Babypants, along with other popular children's music artists and folk songs. These programs encourage our littlest rockstars in movement, song, dance, play, and story time all in one 45 min class!

STUDENT INFORMATION

First Name *

Last Name *

Pronouns

Birth Date * +

Does the student have any medical, learning, behavioral, or other special considerations/circumstances of which we should be aware? If yes, please explain: *

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CONTACT INFO

PRIMARY ADULT

Relationship to Student: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address *

City *

State *

Zip *

Phone *

Alternate Phone

Email Address *

SECONDARY ADULT/EMERGENCY CONTACT

Relationship to Student: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Street Address

Address Line 2

City

State

Zip Code

Phone Number *

Email Address

TINY MUSICIANS CLASS SELECTION

This is our music class for ages 0-4.

Please select the days and times you will be attending class. The fee is $80 for a four-week session. This includes a spot for one child* and one accompanying adult.

*siblings okay, please fill out one form per child

January

Fridays 1/5, 1/12, 1/19, 1/26

10:00-10:45 am

Saturdays 1/6, 1/13, 1/20, 1/27

10:00-10:45 am

February

Fridays 2/2, 2/9, 2/16, 2/23

10:00-10:45 am

Saturdays 2/3, 2/10, 2/17, 2/24

10:00-10:45 am

PAYMENT

*If you are using the Pay What You Can option, please select a 100% scholarship and then enter the amount you are able to pay below.*

Scholarships are available for any and all! Please select partial or full scholarship below.

We also offer Pay What You Can. Please enter the amount you are able to pay below, after requesting a 100% scholarship. No student will be turned away for lack of funds.

If you have a Promo Code, enter it here.

Please enter below any amount you would like to donate to our programming here at MMPA. This helps us continue to provide classes to families in need of free and reduced rates!

Current Total:

$0.00

DEMOGRAPHIC INFORMATION

Any and all demographic information is optional and any answers will be confidential. Demographic information received will be used by MMPA to receive funding to keep the cost of our programs affordable to all students. Please complete this section to the best of your ability & comfort level.

Ethnicity

Household Size

Annual Household Income

Primary Language Spoken at Home

COVID-19 SAFETY PROTOCOL

I, the undersigned, agree to help protect the health and safety of all MMPA students and staff by adhering to the following protocol:

- If either parent or child is exhibiting symptoms of illness (i.e. fever, headache, sore throat, stuffy/runny nose, fatigue, etc.), I will notify MMPA and stay home. We will not return to class until the symptoms subside.

- If any member of my household has known exposure to COVID-19, I will notify MMPA immediately so that they can communicate with the families of classmates.

- Masks are optional. We encourage you to do whatever makes you feel most comfortable. *

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PHOTO/VIDEO RELEASE

*

I give my permission.

I DO NOT give my permission.

Mode Music and Performing Arts (“MMPA”) is requesting permission to use images and videos from our programming for the purpose of advertising and for the promotion of our non-profit to charitable foundations so we can continue to provide art classes and music lessons to all children, regardless of income. I hereby allow MMPA to use images of my child in these applications and requests. MMPA will notify me of classes that will be recorded or have screen images captured prior to the class. *

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COMPLETION

I, the undersigned parent/guardian of the registrant, acknowledge the possibility that participation in Mode Music and Performing Arts activities could result in physical injury to the registrant. I hereby release, discharge and agree to hold harmless Mode Music and Performing Arts, its officers, directors, employees, agents and affiliates from any and all claims arising from or related to the registrant’s participation in Mode Music and Performing Arts activities. I certify that I have read, understood, and agree to the above conditions, and that the information provided is complete and accurate to the best of my knowledge. *

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