Keys To Life Inquiry Form

Thank you for your interest in the Keys to Life (KTL) after-school program at Fundamentals Music Academy!

Please fill out the form below, and we’ll be in touch to discuss availability, learn more about your child and their needs and next steps.

Student Information

Full Name

Birthday

Month

Day

Year

Current Grade

School Name

Home Address

City State

State

Zip

T-Shirt Size

Youth

Adult

Parent/ Guardian Information

Primary Parent/Guardian

Full Name

Relationship to Student

Phone

Email

Secondary Parent/Guardian (Optional)

Full Name

Relationship to Student

Phone Number

Email

Emergency Contact (Other than Parent/Guardian)

Full Name

Relationship to Student

Phone Number

Medical Information

Does your child have any allergies?

Yes

No

If yes, please list:

Does your child have any medical conditions or special needs we should be aware of?

Yes

No

If yes, please explain:

Program Information

Which component(s) of KTL are you most interested in for your child? (Check all that apply)

A Little Me Time (Cultural Exploration)

Safe Space (Emotional Support)

Musical Activities (Songwriting, Beat Making, Collaboration)

Tutoring (Homework Support)

Permissions & Agreements

Media Release: I hereby grant permission for Fundamentals Music Academy and its partners to photograph or video my child during program activities for promotional purposes.

Yes

No

Emergency Medical Authorization: In case of emergency, I authorize KTL staﬀ to secure medical treatment for my child if I cannot be reached.

Yes

No

Code of Conduct Acknowledgment:

I understand that my child is expected to follow program rules and guidelines to ensure a safe and respectful environment.

Yes, I acknowledge

Transportation Permission (if applicable):

My child has permission to be transported for approved KTL activities.

Yes

No

Not Applicable

Signature

Parent/Guardian Name (Print)

Parent/Guardian Signature

Signature field is empty.

Date

Month

Day

Year

Keys To Life Inquiry Form

Student Information

Parent/ Guardian Information

Primary Parent/Guardian

Secondary Parent/Guardian (Optional)

Emergency Contact (Other than Parent/Guardian)

Medical Information

Program Information

Permissions & Agreements

Code of Conduct Acknowledgment:

Transportation Permission (if applicable):

Signature

Hours

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