Private Music Lessons Program Application

Please complete this form to apply to participate in our Private Music Lessons Program. Applications will be reviewed by our team, and Dr. Rhoda Bernard, the Berklee Institute for Accessible Arts Education managing director, will contact you directly to arrange a follow-up meeting and/or phone call.

For questions or more information, please contact Bernard by email at rbernard@berklee.edu or by phone at 617-747-2760.

Thank you for your interest in this program; we look forward to meeting you soon.

Participant Information

Participant's Legal First Name

Participant's Legal Last Name

Participant's Age (as of September 1)

Participant's Date of Birth

Student's Sex at Birth

Name of the School the Participant Attends (as of September 1)

Grade Level (as of September 1)

Citizenship

Country of Citizenship

Country of Birth

Colleges and universities are often asked by the federal government, accrediting associations, college guides, newspapers, and our own college/university communities, to describe the racial/ethnic backgrounds of our community members. In order to respond to these requests, we ask you to answer the following question:

Please check one or more of the following groups in which you consider yourself to be a member:

Primary Language

Participant's Specific Diagnosis

All participants in the Private Music Lessons Program must have a diagnosed disability. Individuals who do not have a diagnosed disability cannot participate in the program.

Family Information

Parent or Guardian's Name

Parent or Guardian's Email Address

Parent or Guardian's Relationship to the Participant

Parent or Guardian's Telephone Numbers

Parent or Guardian's Address Line 1

Parent or Guardian's Address Line 2

City

State/Province

Postal Code

Country

Participation is dependent on acceptance to the program and availability.

Program Information

Instrument(s) the Participant Wishes to Study in the Program

Do you own the instrument(s) that the participant wishes to study?

If you do not currently own the instrument(s), will you purchase the instrument(s) before the lessons begin?

Participants must own the instrument that they study in our program in order to practice at home. Participants will not be permitted to take lessons if they do not own the instrument.

Instrument(s) the Participant Has Played

Length of Time the Participant Has Played Each Instrument

Does the participant participate in a school music ensemble (band, orchestra, chorus, jazz band, etc.)?

Does the participant require support (such as a one-to-one aide) to participate in the ensemble?

Has the participant performed in a recital or other musical performance?

How often does the participant take lessons?

How long is each lesson?

What music book(s) is the participant currently using?

What pieces of music is the participant currently working on?

Can the participant read music independently?

Can the participant sight-read unfamiliar music accurately?

Can the participant play music by ear?

Please describe in detail any key phrases or motivational phrases that are used during the lesson to encourage the participant..

How does the participant communicate?

How does the participant express their feelings?

Please describe in detail any sensory issues that the participant may have that might impact the lesson, and provide information about ways to manage those issues effectively.

Please describe in detail any attention issues that the participant may have that might impact the lesson, and provide information about ways to manage those issues effectively.

Please describe in detail any behavioral issues that the participant may have that might impact the lesson, and provide information about ways to manage those issues effectively.

Private Music Instructor's Name

Private Music Instructor's Email

Private Music Instructor's Phone Number

Does the participant enjoy playing an instrument?

Does the participant enjoy their instrument lessons?

What is the most challenging part of music instruction for the participant?

What is the easiest part of music instruction for the participant?

What type(s) of music does the participant play during the lessons?

What type(s) of music does the participant prefer to play?

What type(s) of music does the participant enjoy listening to?

Please list any concerts that the participant has attended.

Please list the participant's hobbies.

What does the participant enjoy doing in their spare time?

What motivates the participant?

What does the participant dislike doing?

What is your vision for the participant?

Please provide any other information that will help us to better understand the participant and their musical needs.

How did you hear about this program?

Release of Liability

By typing my name in the field below, I, for myself, for my child, do hereby release Berklee College of Music, its principals, trustees, directors, officers, agents, employees, and the staff and instructors from the Berklee Institute for Accessible Arts Education from all liability with respect to my child, and I waive any claim for damages arising from any cause whatsoever, including, but not limited to, claims that my child was less than successful in the Private Music Lessons Program.

Type Name for Release of Liability

By typing my name in the field below, I hereby consent to and authorize Berklee College of Music and/or any of its vendors and their representatives to use still photographs, video footage, and audio recordings of my child in films, video, and audio presentations for associated nonprofit purposes, including a documentary film designed to promote public awareness and education about autism, and for fundraising purposes. I hereby waive any rights to privacy or compensation regarding my authorized release of this video and audio material, and I agree to hold Berklee College of Music harmless from any and all claims relating to my authorized release of said material. I understand that usage of the video/audio may be seen/heard by the general public on Berklee's website(s) and in public or private screenings, and I understand that Berklee College of Music has full and complete rights to those images.

Type Name for Video/Audio Release

Student Code of Conduct

All participants are expected to abide by the Student Code of Community Standards. Due to the range of participants involved in the program, there are additional policies in effect that are designed and enforced to ensure the safety and wellbeing of the participants participating. Private Music Lessons Program participants must abide by the following policies.

1. Possession and/or use of alcoholic beverages is prohibited, regardless of age. It is also a violation to be in the presence of or under the influence of alcohol and/or drugs while at the Private Music Lessons Program.

2. Sexual activity is prohibited while participating in the program. Any activity which is a violation of Massachusetts General Law c.265, s.23 (commonly known as the Statutory Rape Law) regarding statutory rape and abuse of a child is unlawful and in violation of the standards. Also, please understand that by law we may be required to report this behavior to state authorities, and such behavior may also be grounds for immediate dismissal from the program without reimbursement of tuition and fees. Please note that in Massachusetts, this law defines a child as someone under the age of 16.

3. Participants must abide by the check-in policies as prescribed by their program.

Violations of these standards will be investigated swiftly and may lead to immediate removal from the program without reimbursement of fees, as well as parental notification. There is zero tolerance for violations of the alcohol and drug policy, and such violations will result in removal from the program.

Participant Waiver, Assumption of Risk, and Publicity

This is a release of liability and assumption of risk agreement. Read it carefully before signing. In consideration for being permitted to participate in Berklee College of Music ("Berklee") programs (the "Program"), the receipt and sufficiency of which is hereby acknowledged, I agree as follows:

(1) Voluntary Participation and Assumption of Risk. I understand and confirm that my participation in the Program is voluntary, and I fully understand and appreciate the dangers, hazards, and risks inherent in the Program and in any independent travel or activities I may undertake as an adjunct to the Program, including, but not limited to, property damage, bodily injury, personal injury, and death. I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation in the Program and accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in the Program.

(2) Release, Waiver, and Indemnity. I hereby waive, release, forever discharge, and covenant not to sue Berklee and its directors, officers, trustees, employees, agents, volunteers, successors, and assigns, from any and all liability for and waive any and all claims for injury, loss, or damage of any type, including attorneys' fees, in any way connected with my participation in the Program, whether or not caused in whole or part by the negligence of Berklee or any of the individuals mentioned above. I further agree to save and hold harmless, indemnify, and defend the College from any claim by me or my family, arising out of my participation in the Program. I also agree to hold Berklee harmless from any loss, liability, damage, or cost that Berklee or any third party may incur due to my participation in the Program.

(3) Publicity Release. I hereby acknowledge and agree that, beginning as of the date of execution of this Agreement and continuing after the conclusion of the Program, any photographs, videos, images, and/or audio recordings (collectively "Pictures or Recordings") may be taken of me, individually or with others, by or on behalf of Berklee in connection with the Program, and agree that all rights therein shall irrevocably, exclusively, unconditionally, and perpetually belong to Berklee, and that such rights are freely assignable by Berklee. I further agree that, without any compensation or notification to or approval by me, the Pictures or Recordings may be used, reproduced, or otherwise disseminated or published by or on behalf of Berklee, directly or indirectly for any purpose, including, but not limited to, advertising and/or promotional purposes.

(4) General Provisions. This Agreement shall be governed by the laws of the Commonwealth of Massachusetts, U.S., regardless of where the Program takes place. I agree to submit to the exclusive jurisdiction of the state and federal courts of the Commonwealth of Massachusetts to resolve any disputes arising hereunder or related in any manner to my participation in the Program(s). I agree that this Agreement is intended to be as broad and inclusive as permitted by law. The terms and provisions of this Agreement shall be severable, such that if any term is for any reason held to be unenforceable or in conflict with any law applicable to this Agreement, the validity of the remaining portions shall not be affected. This Agreement constitutes the entire agreement pertaining to the subject matter, and no oral representations, promises, or inducements not expressly contained herein have been made.

I have read the foregoing before affixing my name below and warrant that I fully understand the contents thereof.

Parent or guardian: type your name for the release of liability.

Date

Emergency Contact Information

Provide contact information for an individual in case of an emergency.

Emergency Contact Information: Contact 1

This emergency contact is a parent/guardian

First Name

Last Name

Email Address

Mobile Phone Number

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

Emergency Contact Information: Contact 2

Provide contact information for an individual in case of an emergency.

This emergency contact is a parent/guardian

First Name

Last Name

Email Address

Mobile Phone Number

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

Healthcare Provider Information

Family Doctor

Family Doctor's Phone Number

Family Dentist

Family Dentist's Phone Number

Medical Insurance

Group Number

Company Name

Medical Insurance ID Number

Medical Insurance Member Name

Medical History

Allergies, If Any, Including Medications and Foods

Chronic or Existing Diseases or Medical Problems (i.e., diabetes, epilepsy)

Medications Participant Is Now Taking, and Dosages

Date of Last Tetanus Injection or Booster (if known)

Please note: Our staff cannot administer any medications, prescription or nonprescription, to program attendees. The program nurse may administer nonprescription medications, such as Advil or Tylenol, only after speaking with a parent or guardian. If the attendee will need to take prescription medications while attending the program, they must assume responsibility for taking the medication as needed or indicated. Please indicate your permission for your child to self-administer the medication(s) listed above by signing this form.

By signing, I certify that the above-named participant is physically fit to participate in a Berklee program. The health information provided on this form is correct to the best of my knowledge.

Parent or guardian: type your name to sign the Emergency Contact, Health Care Provider, and Medical History sections of this form.

Date

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