Student Information Form

First Name:

Last Name:

Student Date of Birth:

Gender:
MaleFemale

Street Address Line 1:

Street Address Line 2:

City:

State:

Zip Code:

County:

Home Phone:

Student Cell Phone:

Student Email:

Student Instrument:

School you attend:

Grade Attending (2016-17):
K1st2nd3rd4th5th6th7th8th9th10th11th12th

Residence Area (for grant purposes):
RuralUrban

Age Bracket (for grant purposes):
6-1213-19

Race (for grant purposes):
AsianBlackHispanicWhiteOther

Private Teacher's Name:

Is the student in his/her School Band/Orchestra/Choir?
YesNo

If yes, Director's Name:

Father's First Name:

Father's Last Name:

Father at same address as student?
YesNo

Father's Employer:

Father's Occupation:

Father's Work Number:

Father Cell Number:

Mother's First Name:

Mother's Last Name:

Mother at same address as student?
YesNo

Mother's Employer:

Mother's Occupation:

Mother's Work Number:

Mother Cell Number:

Preferred Email address for Billing and Important Information:

My family and I have read the Ethos Student/Parent Handbook found under the Information Tab at www.EthosMusic.net