New Student Application - Junior Academy

Jazz Hands for Autism

10220 Culver Blvd, Ste 101, Culver City, CA 90232

Student Application - Junior Academy

New Student Application (JHJA)

**Complete this form if you are applying for our Junior Academy.
**This form is for NEW / FIRST TIME STUDENTS ONLY. Do NOT complete this form if you are returning or not a first time student.

If you are returning for the next session, please complete this form: JHJA RETURNING REGISTRATION

We accept students quarterly. Please check out our JHJA CALENDAR for registration dates.

Welcome to the Jazz Hands Junior Academy (JHJA). Please fill out this intake form
**Select - Junior Academy (JHJA) as Program

Click Here if you are applying for the Jazz Hands For Autism Musicians Academy (Adults) or if you'd like to be in our Musician Roster.

For other inquiries, email us at info@jazzhandsforautism.org

Please Note: Questions on this form are for the sole purpose of collecting background information on each student in order to develop an individualized music lessons to meet his/her unique needs. All given information is strictly confidential.

1. Complete this form.
2. Set up time to meet with the Executive Director CLICK HERE to set up Zoom meeting.

Program

BACKGROUND

Fill out with the information of applicant

Name of Person filling out form

First Name

Middle Name

Last Name

Preferred First Name

what do you want to be called?

Birth Date

Pronouns

Other (Pronouns)

put N/A if not applicable

Gender

Other (Gender)

put N/A if not applicable

CONTACT INFO

please include billing address below

Student Personal Email

nonJHFA Email

Cell Phone

Home Phone

Street

City

State/Province

Zip/Postcode

Country

EMERGENCY CONTACT

Name of Emergency Contact 1

Relationship with Student of Emergency Contact 1

Phone of Emergency Contact 1

Email of Emergency Contact 1

Name of Emergency Contact 2

put N/A if not applicable

Relationship with Student of Emergency Contact 2

put N/A if not applicable

Phone of Emergency Contact 2

put N/A if not applicable

Email of Emergency Contact 2

put N/A if not applicable

Name of Emergency Contact 3

put N/A if not applicable

Relationship with Student of Emergency Contact 3

put N/A if not applicable

Phone of Emergency Contact 3

put N/A if not applicable

Email of Emergency Contact 3

put N/A if not applicable

Emergency Contact Notes

INTERESTS

Is this student currently enrolled in school or any other programs?

What do you hope to benefit/learn from this program?

what do you want to learn, what are your goals by the end of this program, what do you need help on, etc.

Student Biography

Non Musical Skills and Strengths

What other talents or skills do you have aside from music? (acting, drawing, animation, etc)

Other Non Musical interests

What other interest do you have aside from music? (acting, drawing, animation, etc)

MUSICAL INFORMATION

Primary Instrument

What is the top instrument do you want to learn or be better at?

Other Primary Instrument

put N/A if not applicable

Other Additional Instruments

put N/A if not applicable

Stage Name

How do you want to be called as an Artist?

Musical Preferences

What musical skills do you want to learn? What musical preferences when learning?

Song Choices

What songs do you want to learn? What song genres are you open to learn? Write the name of the song and the original artist. If it is an original song, please indicate that

Musical Experiences

Describe any musical experience you had in the past. mention instruments if applicable (#years playing, how was trained with instrument, self taught/1on1 lessons). Mention any music production software you have experience in if applicable

ACCOMMODATIONS

Any Special Arrangements, assistance student needs,etc.

Diagnoses

Please include all diagnoses including behavioral, developmental and medical put N/A if not applicable

Current Medications

put N/A if not applicable

Allergies

put N/A if not applicable

What special arrangements does this individual require?

(mobility arrangements, one-on-one staff, nonverbal, etc. If none, please enter N/A)

Taking Breaks (explain)

Do you need long breaks or short breaks? How long can you focus in class? How many back to back classes are you okay with taking? Do you need long breaks(1hr) or short breaks (5-15 min) if you are taking 4-6 back to back classes in one day? Explain.

What is the child's social/emotional status? How would you describe their ability to self-advocate?

Communication: How does student communicate?

Explain way of communication, if Verbal or non verbal. Does this student possess any difficulties in communication? Indicate N/A if not applicable

Best method to contact student

Other method to contact student

put N/A if not applicable

Languages Spoken

Add notes/Explain if need be

Where do you live?

Pick the one that best explains your learning environment at home

Other (where do you live)

put N/A if not applicable

What learning materials do you have?

desktop

laptop

Notebooks

pencils

Other

Check the boxes of all materials you have. You can select multiple learning materials

Other (Learning materials)

put N/A if not applicable

Do you have internet connection?

Tell us what type of internet connection you have

Other (Internet Connection)

Put N/A if not applicable

Do you know how to use Zoom?

Which program format do you prefer?

Name of Support Staff 1

ABA Therapist, Communication Partner, etc. Put N/A if none

Email Address of Support Staff 1

Name of Support Staff 2

ABA Therapist, Communication Partner, etc. Put N/A if none

Email Address of Support Staff 2

Name of Support Staff 3

ABA Therapist, Communication Partner, etc. Put N/A if none

Email Address of Support Staff 3

Are you a client of the regional center?

Regional center

Choose

Other Regional Center

put N/A if not applicable

Name of Service Coordinator

put N/A if not applicable

Email of Service Coordinator

put N/A if not applicable

Phone of Service Coordinator

put N/A if not applicable

PROGRAM PAYMENT

This Program Offers: 12 week Zoom/ In Home Instrument Training (piano or guitar lessons)

Cost (online):
$75 per hour
$56.25 for 45 mins
$37.50 for 30 mins

Cost (in person):
$84 per hour
$63 for 45 min
$42 for 30 min

Two Payment Options:
OPTION A: Pay upfront for 11 or 12 weeks. Payment is due on the third before the first week of the session.
OPTION B-1: Payment (for the upcoming month’s lessons) is due on the third of each month. For example, payment for lessons scheduled in June are due on June 3rd.
OPTION B-2: Payment for Self Determination Program student’s lessons are due on the third of the following month. For example, payment for all the lessons (hours) the student attended in July is due on August 3rd.

How long do you want each lesson to be? (JHJA)

JHJA only

How many lessons a week do you want? (JHJA)

JHJA only; 1 lesson, 2 lesson, 3 lesson, etc.

How do you want to have your lessons? (JHJA)

Payment Method (JHJA)

JHJA only

Other - Payment Method (JHJA)

JHJA only

Billing Name

Street

State/Province

City

Zip/Postcode

Weekly Availability For Lessons

Fill out your weekly availability to help us get an idea how to build your class schedule.

Availability Notes

Write down additional comments about your weekly availability

DEMOGRAPHIC INFO

For JHFA data and report purposes. Choices based on 2020 U.S. Census. Check all that apply. Specify more details on.

What is race?
The Census Bureau defines race as a person’s self-identification with one or more social groups. An individual can report as White, Black or African American, Asian, American Indian and Alaska Native, Native Hawaiian and Other Pacific Islander, or some other race. Survey respondents may report multiple races.

What is ethnicity?
Ethnicity determines whether a person is of Hispanic origin or not. For this reason, ethnicity is broken out in two categories, Hispanic or Latino and Not Hispanic or Latino. Hispanics may report as any race.

Is the student of Hispanic, Latino or Spanish origin?

Other Race

If you have selected

ADDITIONAL INFO

How did you find out about JHFA?

Other ways to find out about JHFA

put N/A if not applicable

Has the participant performed at a Jazz Hands Concert (JHCS)?

DOCUMENTS TO SIGN

Please sign this photo and video release form here

For any additional questions, please email us at info@jazzhandsforautism.org with subject line: INTAKE/ADMISSION - Junior Academy

Student Application Signature

Parent's Signature

Date Signed

Today's Date

By signing this, I have filled out this form to the best of my ability. For any changes, I will inform JHFA by sending an email to info@jazzhandsforautism.org