Mixin’ With Beats Student Application

Name(Required)

Prefix First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender(Required)

Male

Female

Other

School

Grade

Name of Authorized Emergency Contact(Required)

Prefix First Middle Last Suffix

Day Phone(Required)

Evening Phone(Required)

Cell Phone(Required)

Email(Required)

Enter Email Confirm Email

Name of Alt Parent/Guardian

Prefix First Middle Last Suffix

Day Phone

Evening Phone

Cel Phone

Enter Email Confirm Email

Medical Information - Specify any of your child’s health concerns/allergies:(Required)

Name of Authorized Emergency Contact(Required)

Prefix First Middle Last Suffix

Emergency Contact Phone Number(Required)

Name of Authorized Emergency Contact

Prefix First Middle Last Suffix

Emergency Contact Phone Number

By listing these emergency contacts, you are authorizing them to pick up your child in the event you are unable to be reached. Any authorized adult will need to show valid identification when picking up a Mixin’ with Beats Academy student.

Agreements:(Required)

I understand and agree that my child is expected to attend all scheduled sessions of the Mixin’ with Beats Academy and follow the CDC COVID-19 requirements, beginning Tuesday, January 11, 2022.

I understand and agree that my child is required to wear a mask to each session.

Media Participation: During the 2022-23 year there will be times when Robinson & Powell Associates of Hampton Roads, Inc. - Mixin’ with Beats Academy and organizations authorized by Robinson & Powell Associates of Hampton Roads, Inc. - Mixin’ with Beats Academy, such as media representatives, will seek to interview, photograph, audio record and/or videotape students during regular sessions. This participation may lead to a student being featured in publications, social media, websites, television programs, radio shows, video productions, or podcasts. The student being featured may have their name, grade, school, image, photograph, voice, artwork, or other information shown, displayed, or recorded, as related to the feature participation. Please note Robinson & Powell Associates of Hampton Roads, Inc.- Mixin’ with Beats Academy carefully screens any requests from outside groups to help ensure that student work and accomplishments are highlighted in a responsible and appropriate way. If you check the next line, Robinson & Powell Associates of Hampton Roads, Inc. – Mixin’ with Beats Academy will NOT release your child’s information to allow participation in such activities.

Media Participation:

Do NOT use my child’s photograph, image, name, or voice in any outside agencies and/or Robinson & Powell Associates of Hampton Roads, Inc. – Mixin with Beats Academy print materials, productions, or website/social media channels.

Name(Required)

Prefix First Middle Last Suffix

Date(Required)