Matts Music Memorial Student Application

* required field

Student Information

First Name *

Last Name *

Physical Street Address *

Physical City *

Physical State *

Physical Zip Code *

Mailing Street Address (if different than Physical)

Mailing City (if different than Physical)

Mailing State (if different than Physical)

Mailing Zip Code (if different than Physical)

Student email (if available):

Phone Number (if available):

Format: 1234567890 Home Cell Office Other Cell Provider (if applicable)

Gender *

Male Female Prefer Not to Answer

Birthday: *

Grade starting this fall *

1st Instrument Choice *

2nd Instrument Choice (if student has one)

Parent/Guardian Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian email: *

Parent/Guardian Phone Number *

Format: 1234567890 Home Cell Office Other Cell Provider (if applicable)

Relationship to child *

Parent/Guardian 2 First Name (if applicable)

Parent/Guardian 2 Last Name

Parent/Guardian 2 email:

Parent/Guardian 2 Phone Number

Format: 1234567890 Home Cell Office Other Cell Provider (if applicable)

Parent/Guardian 2 Relationship to child

Demographic Information

To assist us with applying for grants to fund this program, we would appreciate it if you answer the question below. Please note, this is only for grant writing purposes and no answer disqualifies your application.

Does anyone in your household receive:

Free Lunch Reduced Lunch Needs Based Scholarship Other Public Assistance None

If this program did not exist, would this student still be able to participate in Band?

Definitely would Probably would Probably would not Definitely would not

School Information

School Name *

Instructor First Name *

Instructor Last Name *

Instructor email (if known):

Instructor Direct Phone Number (if known)

Format: 1234567890

Delivery date requested: *

First-year students: This is NOT usually the first day of school. Please refer to the information received from your school. Returning Students: This is typically the first day of school. Delivery by this date is not guaranteed, but this helps us manage inventory wisely. Actual delivery of instruments is dependent on when and how many applications are received.

Other Information

Other Notes

Student Essay Upload

Please provide a legibly written or typed response to one or more of the following questions using at least 100 words:

Why did you pick your instrument?

Why do you want to study instrumental music?

How has music influenced your life?

File must be a scanned pdf or picture of the students essay (PDF,JPG,JPEG,PNG ONLY).

*** A student essey is required to complete scholarship application. If you experience an issue with the upload please complete this application and hit submit without an attachment, then email the student's name and essay to mattsmusicmemorial@gmail.com.

Terms and Conditions * -

I have read and agree that by submitting this application, we (Student and Parent) hereby acknowledge that we are responsible for day-to-day maintenance of any instrument issued to our family. We pledge to repair or replace any instrument that has damage which resulted from negligence. We agree to keep Matt’s Music Memorial informed of any changes to the above contact information and notify them of any issues or concerns regarding the instrument in our possession. When the above-named student is no longer active in an approved band program, we agree to promptly return the instrument to Matt’s Music Memorial.

I Agree

*** If you are receiving yellow boxes or error notes, please check any boxes that autofilled as well as the file type you are uploading. If you continue to have issues with submission, please email mattsmusicmemorial@gmail.com.

Scholarship Application

We are so excited that your child is interested in pursuing music!

Please fill out the below information to request an instrument from Matt's Music Memorial.

If you have any issues with this form, please email MattsMusicMemorial@gmail.com or call Kara at 402-670-1806.

Student Information

Parent/Guardian Information

Demographic Information

School Information

Other Information

Student Essay Upload

Please provide a legibly written or typed response to one or more of the following questions using at least 100 words:

Why did you pick your instrument?

Why do you want to study instrumental music?

How has music influenced your life?