Student Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian Phone (If different from above)

(###)

###

####

Parent / Guardian Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have access to a practice instrument *

Yes

No

Do you have transportation to and from the lesson

Yes

No

Please indicate your last year's adjusted gross family income: *

Please check one of the box below

Less than $25,000

$25,000-$34,999

$35,000-$44,999

$45,000-$49,999

$50,000-$59,999

Over $60,000

Please check ALL the boxes below:

By checking this box, I understand that Massachusetts Music Teachers Association seeks to award financial assistance to those who have genuine financial need and does not discriminate in matters of race, color, gender or gender identity, national or ethnic origin, religion, health condition or disability. To the best of my knowledge, the information given on this application is correct. MMTA and its Music Connect Program Committee will regard all financial information as strictly confidential. The MMTA’s Music Connect Program Committee reserves the right to ask for additional financial information.

I have read and I accept and agree to the terms of MMTA's Music Connect Program stated separately in the "Description for Student's Parent or Guardian"

Date *

Today's date

MM

DD

YYYY