Emergency Contact Form

In order to keep a safe environment and to provide School of Music communications to parents and students, all persons taking lessons at the PYCO School of Music MUST fill out the emergency contact form below. Please fill out one form per student.

* Indicates required field

Student First Name *

Student Last Name *

Instrument 1 *

Private Teacher 1 *

Instrument 2 *

Private Teacher 2 *

Student Email (if applicable) *

Date this form was filled out (MM/DD/YYYY) *

Student Age (by date this form was filled out) *

Student Grade (if filling out this form in the summer, indicate grade completed) *

School *

School District *

Parent/Guardian Name 1 *

Parent/Guardian Name 2 *

Parent/Guardian Email 1 *

Parent/Guardian Email 2 *

Student Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent/Guardian Address, if different from student *

Line 1

Line 2

City

State

Zip Code

Country

Main Contact Name *

Main Contact Telephone *

Emergency or Alternate Contact Name *

Emergency or Alternate Contact Telephone *

I, the undersigned, as Parent/Guardian of the above named minor do hereby release the PYCO School of Music, its employees and instructors, from any and all liability. This Includes any accident that may occur or illness that may be contracted, including but not limited to COVID-19, while my child is at the facility. *

Please write any comments or questions below. *

Submit