Fillable School of Piano Application (The Chickasaw Nation)

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School of Piano Application (The Chickasaw Nation)

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Page 1 of 2 Form no. 05051P CH-AH 7/2019
School of Piano Application
2019 Fall Semester September - December
Name:
First Middle Last Suffix
Affiliation: (please select one that best applies to the student)
☐ Chickasaw/Chickasaw family (FREE) ☐ Other tribe (FREE) ☐ Non-native/CN employee ($10/month)
Mailing address:
Street/P.O. Box City State ZIP
□ Same as mailing address
Physical address:
Street City State ZIP
Birth date: Email:
Please list an email that you check regularly
Age in August 2019: Phone: ( )
Do you text: □ Yes □ No Do you own/have access to a piano? □ Yes □ No
Please choose: □ Wednesday □ Thursday
Emergency contact: (Please list two local individuals to call in case of an emergency.)
Name: Phone:
Name: Phone:
Class selection: (Please select the class in which you are interested)
Section:
□ Age 6 – 8, 4 p.m. □ Age 13 -18, 6 p.m.
□ Age 9 – 12, 5 p.m. □ Adults, 7 p.m.
Deadline for application is August 16
th
at 5:00 p.m.
Bill Anoatubby
Governor
Department of Culture and Humanities/Arts and Humanities Division
Performing Arts
Page 2 of 2 Form no. 05051P CH-AH 7/2019
Conduct Agreement
The primary goal of the Chickasaw Nation School of Piano is to provide a safe environment conducive to
learning.
Class attendance and any scheduled performance is imperative. A student/student’s parent/legal guardian is
required to contact Claire Marquardt at (918) 721-3754, or Claire.marquardt14@gmail.com, when he
must be absent. If a student is absent for more than two consecutive classes (or more than five total), the
Chickasaw Nation Performing Arts administration and instructor will determine whether or not a student may
proceed with classes or performances.
The use of tobacco in any form will not be allowed. Use of foul or abusive language, disruptive behavior,
theft, misuse or abuse of public and/or private property or disrespect of other students or staff members will
not be tolerated. Students demonstrating such acts are subject to being dismissed from the program.
The Chickasaw Nation School of Piano reserves the right to place a student in a class other than the day of
the week requested depending on class population/availability. These changes will be communicated to
student/student’s parent/legal guardian. Please note that placement preference will be given based upon
Chickasaw citizenship, previous enrollment and/or attendance record.
By signing this document, you are granting permission for photographs and/or footage of you/your student to
be featured in advertisement and publications for the Chickasaw Nation.
The reason for this agreement is to ensure respectful conduct, behavior, class and performance attendance,
so each student may receive the full benefit of enjoyment and educational experiences this program offers.
By signing below, you agree to the terms and conditions of this agreement.
Student’s signature Date
Parent/legal guardian signature Date
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School of Piano Application (The Chickasaw Nation)

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Completed 31 January 2021

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