Student Name *

First

Last

Age *

Date of Birth *

Grade (2019-2020) *Rising 9th GraderRising 10th GraderRising 11th GraderRising 12th Grader2019 Graduate

Please check your area(s) of specialty or interest. *

• Songwriter
• Poet
• Rapper
• Singer
• Musician
• Engineer
• Producer
• Label Rep

Please share why the are(s) you marked interest you. *

Contact Information

Student Cell # *

Address *

Address Line 1

Address Line 2

City

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Zip Code

Parent/Guardian Name *

First

Last

Parent/Guardian Home #

Parent/Guardian Work #

Parent/Guardian Cell #

Parent Email *

Name

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