Apply for Lessons

Selected Instruments(Required)

Please select which instrument(s) you are interested in. Due to high demand, all instruments have a waitlist and you will be called when a spot opens up.

Bass

Brass

Drums

Guitar

Piano

Voice

Student Section

Student Name(Required)

Gender(Required)

Date of Birth(Required)

Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Primary Phone Number(Required)

Primary Phone Type

Email Address(Required)

School(Required)

Expected High School Graduation Year(Required)

Languages Spoken(Required)

Race/Ethnicity(Required)

Participant Characteristics

Parent/Guardian 1 information

Parent/Guardian 1 Name(Required)

Parent/Guardian 1 Relationship(Required)

Parent/Guardian 1 Primary Number

Parent/Guardian 1 Primary Phone Type

Parent/Guardian 1 Secondary Number

Parent/Guardian 1 Secondary Phone Type

Parent/Guardian 1 Email Address(Required)

Parent/Guardian 2 information

Parent/Guardian 2 Name

Parent/Guardian 2 Relationship

Parent/Guardian 2 Primary Number

Parent/Guardian 2 Primary Phone Type

Parent/Guardian 2 Secondary Number

Parent/Guardian 2 Secondary Phone Type

Parent/Guardian 2 Email Address

Further information

Does your child need any special accommodations? [Physical, learning, health, developmental, or otherwise.]

US Born?(Required)

Yes

Househould Size(Required)

Both Parents Living in the House?(Required)

Yes

Emergency Contact(Required)

Emergency Contact Relationship(Required)

Emergency Contact Primary Phone Number(Required)

Emergency Contact Primary Phone Type

Emergency Contact Secondary Phone Number

Emergency Contact Secondary Phone Type

How did you hear about ZUMIX?(Required)

Annual Income Amount(Required)

Income Verification Document

This will be required when a student starts programming. It will be kept confidential and only be used for grant-writing purposes. To run our free and low cost programs, we receive government funding and for reporting purposes we need to track participants income levels.

This is the list of eligible income verification forms:

Current report card
Pay Stub or W-2 Form
Masshealth Card
Housing Authority Verification Form
Public Assistance Check
Social Security Benefits
Unemployment Insurance Documents
Letter approving Commonwealth Care Insurance
Authorization to receive Cash Public Assistance
Award Letter from Veterans Administration
Pension Statement

Please upload ONE of the following documents here. You may also provide a paper copy to our office.

Accepted file types: jpg, jpeg, gif, png, pdf, docx, doc, Max. file size: 20 MB.

Parent Signature(Required)

I hereby confirm that the information that I provided on this form is true and accurate to the best of my knowledge. I authorize my son/daughter to participate in ZUMIX, Inc. programs and activities. In giving this authorization, I agree that I will not bring suit against ZUMIX, Inc. including any of its officers, employees, contract staff, agents, or sponsoring agencies for any reason including property damage or personal injury incurred by myself or my son’s/daughter’s participation in ZUMIX, Inc. services, programs, or activities. I also authorize ZUMIX, Inc. to take and use photos, and/or audio/video recordings of my son/daughter while he/she is a participant in ZUMIX, Inc. services, programs, or activities.

All songs recorded for projects at ZUMIX will be considered the composition of the student who wrote them, however ZUMIX shall maintain all rights to the recordings and may use them to represent, market, and raise funds to support their programs. In addition, ZUMIX shall have the right to use images of my child in conjunction with this project to represent, market, and raise funds to support their programs. Students shall not receive compensation (financial or otherwise) for their participation in or creative contribution to ZUMIX programs unless it is part of the program design and the terms have been previously arranged. I understand that any proceeds derived from sales of these products will be used to support further programs at ZUMIX.

I have listed any health problems that my child has and that may affect him/her (example: asthma, taking medication twice daily, allergies, or recent injuries). In the event of a sudden serious injury or illness to my son/daughter whiile he/she is participating in ZUMIX, In. services, programs, or activities, I express my consent for the administration of emergency medical care, including anesthesia, if such action is desirable in the opinion of the attending medical personnel. I shall be responsible for all medical fees and other charges. I understand that the leaders will make a reasonable effort to contact me, should a sudden injury or illness occur.

In signing this application, I certify that my child is covered by health insurance and accident insurance or Medicaid and that I am obligated to provide ZUMIX, Inc. with the name and the carrier and policy number. I understand that if I do not have insurance I shall be responsible for all medical fees and related charges whether I am insured or uninsured.

My typed name below represents my digital signature.

Create an Account with ZUMIX

Create an account with ZUMIX to save your registration information for quick sign up in future semesters.

Create Account

Yes, create a ZUMIX account.

Account Name(Required)

First Last

Account Username(Required)

Account Password(Required)

Enter Password Confirm Password

Account Email(Required)