Name of Student:____________________________________ Grade:________ Age:__________
Address (no P.O. Boxes):___________________________________________________________
Instrument Played (or wanted)_________________________
Parent/Guardian:_________________________________________________________________
Phone: (h)_______________________ (w)___________________(email)___________________
Approx. Yearly Household Income:__________________(gross) Soc. Sec. No.______________
Adults in household (names):______________________________________________________
Minor children/ages in household:__________________________________________________
Non-Custodial Parent Name/Add/SS#:_______________________________________________
Rent or own home? Monthly Payment:_______________
Parent #1's Employer:_______________________________________Phone:________________
Parent #2's Employer:_______________________________________Phone:________________
School District Name/Phone:______________________________________________________
Name/Phone of Instrumental Music Teacher:________________________________________
Ensembles in which student will perform:___________________________________________
Hours per week of lesson instruction:_______________
Group or Private?_______________
Has the student had prior music lessons?
(Circle one) Yes No If
yes, were lessons in school? Yes No
If so, how long? _____________ Which instrument(s)?________________________________
***Please elaborate on back why the student
should receive an instrument from IS.***
Also, if you are a) self-employed, b) unemployed,
or c) on public assistance, you will need
to provide proof of income. Please enclose
a copy of one of the following with your
application: a) front page of Federal Income
Tax return; b) unemployment compensation
letter and pay stub if applicable; c) copy
of letter from the Department of Welfare.
Any copies of letters should state the amount
of benefits received, and the effective dates.
Thank you!
Date:____________ Parent/Guardian Signature:_______________________________________
DIRECTOR'S ACKNOWLEDGEMENT AND AGREEMENT
I, the undersigned music director, approve
the above student for receipt of an Instrumental
Solutions ("IS") instrument. I
acknowledge that upon receipt of an IS instrument,
the above referenced student becomes part
of my school music program, and I agree to
take on the responsibilities associated with
receiving an IS instrument as follows: Coordinating
with IS personnel to ensure student is in
the school program or still in the school
district; facilitating return of instruments
to Instrumental Solutions or their assignees;
filing yearly evaluations promptly as sent
by IS; and notification to IS if the student
moves on to another school in the district.
Failure to do any of the above may result
in my school or my district being removed
from the Instrumental Solutions programs.
Date:___________________ Director:_______________________________________________
School Phone:__________________ Email: ___________________________________
(You may mail your email address to instrumentalsolutions@gmail.com
if you do not want to release it on this
application form. Thank you.)
