Student Enrollment Form
& Release Session 23

Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Returning sINgSPIRE Student *

Yes

No

Returning students, would you like to continue with your same instructor if possible?

Yes, I'd like to continue with my same instructor.

No thanks, I would prefer to try someone new.

Returning students are asked to participate in one Breathe Bravely hosted events per year. Because it's greatly important to our organization that we might continue to give this opportunity to each person at no cost ($450) we ask for your help in making our fundraising events a beautiful representation of the impact of this program - inviting our community to not only sign up for our program but become a part of our story by supporting it.   *

Participation and contributions can come in the form of: Video or written testimonial, Recording a song, writing an impact letter to be sent to donors or shared during educational conferences, actively sharing events through social media and inviting individuals to watch, take part, etc.

Yes! I understand!

This is my first session so does not apply (know we'd love for you to partake if you feel comfortable!)

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

**** Lessons (30 minutes)

*Video-Call Lessons require a reliable Wifi connection & Video device.

Video- Call Lessons

Preferred means of communication: *

Text

Email

Have you taken private music lessons before?

Yes

No

Name

First Name

Last Name

Parent/ Guardian Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Phone *

(###)

###

####

I understand that to be eligible for the sINgSPIRE program I must have a medical diagnosis of cystic fibrosis. *

I understand

This opportunity is provided at no cost to you thanks to a generous donor who has paid the tuition fee of $450 for this spot. By signing up I understand that I am committing to weekly lessons and the expectations set by the assigned instructor and the sINgSPIRE program to the best of my ability.

I understand

Vocal Health *

Please select all that you have experienced within the last 90 days.

Voice loss

Hoarseness

Dry, scratchy throat

Pain when speaking or singing

Breathlessness when speaking

Strained or weak feeling voice

Rough, gravely, low feeling voice

Heaviness in your voice when speaking or singing

You've been told it's hard to hear you when you use your voice

Other

None of the above

I, the undersigned, do hereby grant or deny permission to Breathe Bravely to use the image and/or recording of the above named student, for promotional, informative, and educational purposes for the sINgSPIRE program. * *

Grant

Deny

Grant Permission in the following ways: * *

Educational Usage

Social Usage

Promotional Usage

Not applicable

Upcoming Opportunities I'd be interested in:

sINgSPIRE Virtual Choir Project (Spring 2024)

Workshop: Applying sINgSPIRE Techniques to PFTs

FIKA: Coffee & Conversation (once a month Zoom get together)

JackTrip

LIVE DJ experience

I understand that I am enrolled in the sINgSPIRE program is a 10 week program which consists of weekly private voice lessons via ZOOM. I understand my assigned instructor and I will set a weekly standing time for our lesson. I understand communication with my instructor is imperative if my weekly time does not work. I understand that if I fail to communicate an absence greater than 24 hours in advance more than three times it can jeopardize my enrollment in the program. (Medical or family emergencies do not count against this). I have read and understand the progam policy that was sent via email communication *

I have read the above expectations and understand.

Today's Date *

MM

DD

YYYY