June 3, 2016 frances thrush Student Enrollment Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Your Name * Your Phone * Your Email * Student's Name * Student's Gender * Male Female Student's Ethnicity * Student's Birth Date * Student's Address * Where does the student attend school? * List foster parent's name, email if possible, contact phone number * Caseworker's name, email, phone number * Case Manager's Name, Email, Phone Number * CPS supervisor's name, email, phone number * CASA volunteer's name, email, phone number * List the type of lesson the child is interested in taking * Does the student own the instrument he or she is interested in taking? * DSM diagnosis if applicable * List any additional special issues the child may have (severe allergies, behavioral issues, etc.) * How did you hear about Kids in a New Groove? * Please select an option I currently have children receiving lessons through KING I heard a presentation about KING within the community Website/Social Media Placement Packet Word of Mouth Other If you are a human and are seeing this field, please leave it blank.