Participant Info & Registration Form

Participant Information

Full name

Date of Birth

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Email Address

Primary Phone

Caregiver/Parent/Guardian Information (If applicable)

Full Name

Primary Phone

Email Address

Emergency Contact (other than caregiver/parent/guardian)

Full Name

Relationship

Phone

Participant Details

Instrument(s) Played (if any)

Musical Experience

Beginner

Intermediate

Advanced

None

Which location(s) are you interested in?

Akron, OH

Mentor/Deepwood, OH

Solon, OH

Schnecksville, PA (Union Lutheran Church)

Does the participant have any disabilities, learning differences, or support needs you’d like us to be aware of to make this a successful experience? If yes, what are they?

Are there any physical, medical, sensory, or communication supports that are needed which may be helpful during rehearsals or performances? If yes, what are they?

Medical Information

Allergies (food, medication, environmental):

Medications (please list any taken during program time):

Other Health Concerns (seizures, diabetes, asthma, etc.):

Media & Photo Release

Hearts for Music takes photographs and records video/audio of all of our participants during rehearsals, performances, and related activities. I understand that these images or recordings will be used, without compensation, for promotional, educational, or informational purposes in print, digital, and social media platforms, including the Hearts for Music, Inc. website, brochures, and fundraising materials. This permission is granted indefinitely.

Please click below:

Yes, I understand and give permission

Program Fee Information

Participation in Hearts for Music includes a program fee of $200 per semester. Payment can be made via cash, check (payable to Hearts for Music, Inc), or an approved electronic payment method.

We are committed to making music accessible to everyone. If the program fee presents a financial hardship, please reach out to:

Ohio: info@heartsformusic.org

Pennsylviania: hfmpa@HeartsForMusic.org

Your information will be kept confidential.

We do not want cost to prevent anyone from participating.

Participation Statement

Hearts for Music welcomes all, regardless of ability, disability, race, religion, identity, or background, to be part of our inclusive musical community. No prior musical training or experience is required to participate. Anyone interested in joining us will be guided by the conductor and, if you do not have your own instrument, an iPad will be provided so you can actively engage and contribute as part of the orchestra.

Participants ages 13 and younger must be accompanied by a parent, guardian, or caregiver. If you require personal care assistance, behavioral support, or help with using an instrument or device (such as an iPad), a caregiver or support person must attend with you. While our staff and volunteers are here to foster a positive, supportive environment for all, they are not able to provide personal care or individual behavioral support.

We are committed to creating a welcoming space where everyone can participate, express themselves, and enjoy the joy of making music together.

Consent & Acknowledgement

I understand that Hearts for Music, Inc. provides an inclusive and supportive musical experience for participants of all abilities. I acknowledge that I have shared all necessary information to ensure a safe and positive environment and agree to follow program guidelines.

Parent Signature (if applicable)

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Caregiver/Parent/Guardian Signature (if applicable)

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Date