Page 1 of 2 Form no. 05051G CH-AH 7/2019
School of Guitar Application
Name:
First Middle Last Suffix
Affiliation: (please select one that best applies to the student)
☐ Chickasaw/Chickasaw family ☐ Other tribe/CN employee ☐ Non-native
Mailing address:
Street/P.O. Box City State ZIP
□ Same as mailing address
Physical address:
Street City State ZIP
Birth date: Age in August 2019: Email:
Please list an email that you check regularly
Phone: ( ) Do you text: □ Yes □ No
Allergies:
Behavioral health issues (optional):
This section is completely optional: however, if you feel comfortable sharing, this information will help us to help your student be as
successful as possible in class. This information will not affect class selection.
Parent information: (please complete this section if the applicant is a minor)
Parent name:
First Middle Last Suffix
Birth date (for security purposes): Phone: ( )
Parent name:
First Middle Last Suffix
Birth date (for security purposes): Phone: ( )
Emergency contact: (Please list two individuals (other than parents/legal guardians) to call in case of an emergency.)
Name: Phone:
Name: Phone:
Photo release:
For parents/legal guardians: By signing this document, I am granting permission for photographs and/or
footage of my student(s) to be featured in advertisements and publications for the Chickasaw Nation Dance
Studio.
Parent/legal guardian signature Date
PLEASE COMPLETE BOTH PAGES OF THIS APPLICATION
