SY22-23 Registration/Re-Enrollment Form
Application Screening Questions
Please select your language /// Por favor seleccione su idioma
Has your student previously participated in Kidznotes?
Yes
No
OLDER BEGINNERS: Is your student a
3rd-5th grader
who has NEVER participated in the Kidznotes program previously
?
Yes
No
NEW RECRUITS: Does your student have at least
two
years of experience on an instrument and currently participate in the orchestra/music program at their current school?
Yes
No
Returning Students
Welcome back! Kidznotes is excited to have you involved in the program another year!
NEW STUDENTS: Recruits
Welcome to the Kidznotes! We are excited to have become a part of our community.
NEW STUDENTS: Older Beginners
Welcome to the Kidznotes family! We look forward to having you join our community.
Thanks for your interest in the Kidznotes Program!
At this time, we are only registering students who have previously
participated
in the Kidznotes program, students in grades 3-5 for our Older Beginners program, or recruited students who already have instrumental music experience.
The Mozart Program will begin in mid-October of the 22-23 school year. Mozart registration will occur in the fall, and the application process will be facilitated in partnership with the general music teachers at our partner schools.
Please follow us on social media and check the website for updates in August!
Instagram: @kidz_notes
Facebook: www.facebook.com/kidznotes
www.kidznotes.org/enroll
Questions? Please contact program@kidznotes.org
Student & Family Information
If you would like to re-enroll more than one student, please complete a separate form for each student.
Questions? Contact:
program@kidznotes.org
Student Information
Please choose the city that corresponds with your school district.
Durham
Raleigh
I am registering/re-enrolling a
Returning Student (2-12th grade)
Older Beginner (3rd-5th grade
only
)
New Recruit (never participated in Kidznotes before, but has
two
years of instrument experience)
Student School ID Number
Lunch number
Student First Name
Student Last Name
Student Ethnicity
Please select...
American Indian or Alaska Native
Asian
Biracial
Black or African American
Hispanic or Latino or Spanish Origin
Native Hawaiian or Other Pacific Islander
Other
White
School Other
If other, write your student's ethnicity here:
Family's preferred language
Please select...
English
Spanish
Other
Age
Age by September 14, 2022
Student Date of Birth
How many years has your student been involved with Kidznotes Programming?
Please select...
This is my first year with Kidznotes.
1
2
3
4
5
6
7
8
9
10
11
12
Student's Identified Gender
Female
Male
Non-Binary
Other
Student T-shirt size
Please select...
Youth X-Small
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult 2X Large
Grade
Please select...
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade in the 22/23 School Year
Student's School
Please select...
Bethesda Elementary School
Brogden Middle School
Bugg Elementary
Burton Magnet Elementary School
C.C. Spaulding Elementary
Carrington Middle School
Central Park School for Children
City of Medicine Academy
Club Boulevard Magnet Elementary
Creekside Elementary
Durham School of the Arts
E.K. Powe Elementary School
Easley Year-Round Magnet Elementary School
East Garner Elementary
East Garner Middle School
Eastway Elementary School
Eno Valley Elementary School
Fayetteville Street Elementary School
Forest View Elementary School
George Watts Montessori Magnet School
Githens Middle School
Glenn Elementary School
Healthy Start Academy
Hillandale Elementary School
Hillside High School
Holt Elementary Magnet School
Holton Career and Resource Center
Hope Valley Elementary School
J.D. Clement Early College High School
Jordan High School
Lakewood Elementary School
Lakewood Montessori Middle School
Lowe's Grove Magnet Middle School
Lucas Middle School
Mangum Elementary School
Maureen Joy Charter School
Merrick-Moore Elementary School
Middle College High School at DTCC
Morehead Montessori Magnet School
Neal Magnet Middle School
New Tech High School
Northern High School
Oak Grove Elementary School
Parkwood Elementary School
Pearsontown Magnet Elementary School
Poe Elementary
R. N. Harris Magnet Elementary School
RISE
Riverside High School
Rogers-Herr Year-Round Magnet Middle School
Sandy Ridge Magnet Elementary School
Shepard International Baccalaureate Magnet MS
Southern School of Energy and Sustainability
Southwest Elementary School
Spring Valley Elementary
The Durham Performance Learning Center
The School for Creative Studies
W.G. Pearson Magnet Elementary School
Walnut Creek Elementary
Y.E. Smith Elementary Museum School
Other
School attending in 2022-2023. The schools are listed in alphabetical order. If your school is not listed, please select 'OTHER'
School Other
If other, write your school's name here:
Does your student have an IEP (Individualized Education Program) or 504 Plan?
Yes
No
If yes, please provide a copy of their IEP to Kidznotes.
Please upload a copy of the student's IEP
Are there any health challenges that we should know about your child?
Ex. allergies, asthma, diabetic, etc.
In a few words, please tell us why you are registering or re-enrolling your student in the Kidznotes Program:
Current Instrument Information
What is your student's current instrument? Please select the option for Older Beginner if they are new to the program.
Please select...
My student will be an OLDER BEGINNER and does not currently play an instrument.
Violin
Viola
Cello
Clarinet
Flute
Trumpet
Trombone
Percussion
OLDER BEGINNERS: Please select the TOP THREE instruments that you would be interested in playing. First choice is NOT guaranteed. Instruments will be assigned to students considering choices selected made and ensemble/orchestra needs. FIRST Choice:
Please select...
Violin
Viola
Cello
Clarinet
Flute
Trumpet
Trombone
Percussion
My student is willing to play any instrument
SECOND Choice:
Please select...
Violin
Viola
Cello
Clarinet
Flute
Trumpet
Trombone
Percussion
My student is willing to play any instrument.
THIRD Choice:
Please select...
Violin
Viola
Cello
Clarinet
Flute
Trumpet
Trombone
Percussion
My student is willing to play any instrument.
Family Information and Program Agreements
Family Information
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Relationship to Student
Please select...
Mother
Father
Sibling
Grandmother
Grandfather
Aunt
Uncle
Cousin
Friend
Legal Guardian
Other
Cell Phone Number
Email Address
Kidznotes uses texting and e-mail as our primary form of communication.
Please provide a valid e-mail address
.
I agree to release my contact information for an internal family and teacher directory. The directory will be shared with Kidznotes families to assist with communication.
Yes
No
Is there a separation/divorce/custody concern our staff should be made aware of?
Emergency Contact Information
We will contact this person in the event of an emergency and parent/guardian is not available. Please do not list the same name as your child's primary parent/guardian(s).
Emergency Contact First Name
Emergency Contact Last Name
Contact Relationship to Student
Please select...
Mother
Father
Sibling
Grandmother
Grandfather
Aunt
Uncle
Cousin
Friend
Legal Guardian
Other
Emergency Contact Phone Number
Other Relationship
Additional Information & Program Agreements
Does your family qualify for Free/Reduced Lunch?
Yes
No
Does your family qualify for or receive Governmental Assistance?
Yes
No
Ex. Food Stamps, WIC, etc.
What is your family's household income?
Less than $25,000
$25,000-$50,000
Greater than $50,000
How many WiFi enabled devices does your household have? (Please do not include Smartphones in your count)
Please select...
0
1
2
3
4
More than 5
How many members of your household will need to use a WiFi enabled device for school or work this year?
Please select...
0
1
2
3
4
More than 5
I would like to join the 2022/2023 K-PAC (Kidznotes Parent Advisory Committee). K-PAC is a group of parents supporting the program to build community through communication, event organization, and more.
Yes
No
Students participating in the Kidznotes Program will be actively photographed and videoed during program related activities. Kidznotes uses these photos and videos for social media content, grant reports, advertising, publicity purposes, etc. By signing your full name below, you are verifying that you give permission to Kidznotes and participating partners to use photographs and videos of your student acquired during program related activities for the above mentioned purposes.
(PLEASE TYPE FULL NAME TO SERVE AS SIGNATURE)
Comments
Note special requests/situations you need to make us aware of. (Scheduling conflicts, childcare changes, etc.)
Additional Contact Information
Please fill out the Parent/Guardian 1 information below even if you have given it before.
The Parent/Guardian 2 section is optional.
Parent/Guardian 1 Information
Home Address
Street
City
State
Zip Code
Home Phone Number if Different from Cell Phone
Parent/Guardian 2 Information (Optional)
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Relationship to Student
Please select...
Mother
Father
Sibling
Grandmother
Grandfather
Aunt
Uncle
Cousin
Friend
Legal Guardian
Other
Other Relationship
Home Address
Street
City
State
Zip Code
Parent/Guardian 2 Cell Phone Number
Parent/Guardian 2 Email Address
Thank you for your interest in the Kidznotes Program!
Please follow us on social media and check the website for updates!
Instagram: @kidz_notes
Facebook: www.facebook.com/kidznotes
www.kidznotes.org/enroll
Questions? Please contact program@kidznotes.org
You have completed the registration process for the SY22-23.
You will receive email confirmation to verify form completion from program@kidznotes.org. Please make sure to check your spam if it does not come straight to your inbox, and add program@kidznotes.org to your contacts to prevent that from happening in the future.
We look forward to you being a part of our Kidznotes Community!
Program begins Monday, October 10th, 2022.
Questions? Contact: program@kidznotes.org