STUDENT ENROLLMENT FORM

Section I - Personal Information

Application Date: ___________

Student Name ______________________________

Birthdate ______________

or
Adult Student Name __________________________

Birthdate ______________

Address____________________________________

City __________________

State _______ Zip ____________

San Antonio City Council District # _____

Mother/Guardian Name __________________________

Birthdate ______________

Phone___________________________

Phone (Cell) ___________________________

Email 1___________________________

Email 2 _______________________________

Employer___________________________

Position ______________________________

Employer Address_________________________ Phone________________________________

Father/Guardian Name __________________________

Birthdate ______________

Phone___________________________

Phone (Cell) ___________________________

Email 1___________________________

Email 2 _______________________________

Employer___________________________

Position ______________________________

Employer Address_________________________ Phone________________________________

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Section II - Documentation of Students Disability

(If applying for tuition assistance, please include supporting documentation from all agencies/providers
listed below.)
Primary Diagnosis ______________________________________________________________
Secondary Diagnosis 1: __________________________________________________________
Secondary Diagnosis 2: __________________________________________________________
Is your child verbal?

Type of class in school

Yes

No

ALE

Cognitive Level_____________________________________

INCLUSION

HOMESCHOOL

LIFE SKILLS

IN ORDER FOR DFTM TO BETTER SERVE AND MEET THE NEEDS OF THE STUDENT,
PLEASE COMPLETE THE FOLLOWING:

Is the student receiving educational or community services from any of the following?
School District or Private School: __________________________________________________
Address: __________________________City ________________State _______ Zip ________
Special
Education Coordinator/Principal _____________________________________________
1
1
2
2
Contact
info: (Email) ________________________ (Phone)
____________________________
Community Programs:
Government Agency:
3

REQUIRED IF APPLYING FOR TUITION ASSISTANCE:

STATEMENT THAT ADAPTIVE MUSIC EDUCATION/MUSIC THERAPY IS AN APPROPRIATE MODALITY OF SERVICE FOR
THE STUDENT/CLIENT.

Physician (Primary Care):

_______________________________________________________

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Address: ______________________________________ Phone ________________________

City ______________________________________State _______ Zip ________

Type of Therapy

Times per
week

Therapist Name

SPEECH

PHYSICAL

OCCUPATIONAL

MUSIC/ART

ABA

OTHER ________________________

OTHER ________________________

OTHER ________________________

Email: ___________________________________ FAX _______________________________

Section II - Documentation of Students Disability (continued)
PRIVATE THERAPIES CURRENTLY BEING RECEIVED:

Section IIIA - Documentation for Financial Assistance

IF REQUESTING
ASSISTANCE
FOR THE DFTM
PROGRAM, AND
MEMBER OF
RECEIVES ANY
FOLLOWING
ASSISTANCE,
CURRENT
ANY ONE OF

SSI/ MEDICAID
COPY OF CURRENT MEDICAID CARD

PROOF OF MOST RECENT SSI DIRECT EFT DEPOSIT

FOOD STAMPS / TANF / WIC

RECENT APPROVAL LETTER

HOUSING ASSISTANCE
COPY OF AWARD LETTER

SSDI / MEDICARE
COPY OF AWARD LETTER

PROOF OF MOST RECENT SSDI DIRECT EFT DEPOSIT

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FINANCIAL
WITH TUITION
PRIVATE LESSON
YOU OR ANY
YOUR FAMILY
OF THE
TYPES
PLEASE ATTACH
VERIFICATION OF
THE FOLLOWING.

Section IIIB - Documentation for Financial Assistance

( for those NOT receiving Govt Aid)

DREAMS FULFILLED THROUGH MUSIC recognizes that often families who face the challenges of
providing for a child with special needs do not receive governmental support because they may not
meet certain financial guidelines. In many cases, the medical and other expenses alone prevent the
possibility of providing for a music education. It is our desire to work with families, and to seek
corporate sponsorship to assist with the expenses of tuition, music and instruments.
Complete this section ONLY IF student or family member is not receiving any type of governmental
assistance.
1.

Please tell us what your monthly out of pocket expenses are for the following:

Health Insurance (If any)

Private Therapies (out of pocket costs or co-pays)
Special dietary needs (i.e. gluten/casein free)
Medical Transportation and related expenses (to out-of-town specialists)
Specialized private school tuition
Other expenses
Please explain how these expenses for the child/family member impact the overall family income and
why the family cannot afford the cost of adaptive music education or therapy or if this cost would put a
significant strain on the family budget. In what ways would you be able to provide volunteer hours to
assist DREAMS FULFILLED THROUGH MUSIC? (Use additional pages if necessary.)
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____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Section IV - Parent/Guardian Agreement

I.

I agree to provide the following for my child/family member in order for him/her to receive the
maximum benefit from any adaptive music education or music therapy program.

2.

a,
b.
c.
d.

If my child/family member is awarded tuition assistance or a discounted tuition rate, I agree to

provide volunteer hours to DREAMS FULFILLED THROUGH MUSIC in one or more of the
following areas:

3.

4.

Transportation to lessons on a regular, weekly basis.

Supervised (as recommended by the instructor) regular home practice sessions.
Participation in the lesson as requested by the teacher.
Notification of teacher by phone/email/text if a lesson must be missed due to illness.

a,
b.
c.
d.
e.

Secretarial
Bulletin Board / Display
Outreach / Public Relations
Participation in Major Fundraising Events
Participation in Performance Opportunities of DREAMS FULFILLED THROUGH MUSIC

I agree that DREAMS FULFILLED THROUGH MUSIC may use a photo of my child/family member for
publicity purposes in print media and/or on the DREAMS FULFILLED THROUGH MUSIC website,
including FACEBOOK or YOU TUBE.
I will provide to DREAMS FULFILLED THROUGH MUSIC annually, a signed release form by the
primary care physician of my child or family member.

Page 5 of 6

Date _______________
___________________________

___________________________

Parent / Guardian (Print Name)

Parent / Guardian (Signature)

This completed Application should be returned via email or FAX to:

Dreams Fulfilled Through Music: Private Lesson Program
info@dftm.org
FAX (210) 247-9681

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