SOUTHERN UNIVERSITY DEPARTMENT OF BANDS

BAND MEMBERSHIP APPLICATION FORM

Composite ACT or SAT Score
Enter ACT or SAT Score

Required

Full Name
Enter Full Name

Required

Date of Birth (dd/mm/yyyy)

Required

Address
Enter Address

Required

City:
Enter City

Required

State:
Enter State

Required

Zip code:
Enter Zip

Required

Country:
Enter Country

Required

MaleFemale

Required

SS#
Enter SS#

Required

Parent/Guardian's Name
Enter Parent/Guardian's Name

Required

Are you a Transfer Student?
Yes / No

Required

If so, what college/university are you transferring from?
Enter College / University Name

Required

High School Attended
Enter High School Name

Required

Primary Instrument
Enter Primary Instrument

Required

Years Played
Enter Years Played

Required

Highest Chair Held
Enter Higher Chair Held

Required

Make and Model
Enter Make and Model

Required

Do you own your own instrument?
Yes / No

Required

Years in Band
Enter Years in Band

Required

Secondary Instrument (if any)
Enter Secondary Instrument

Required

Band Director's Name
Enter Band Director's Name

Required

Valid Email Address
Enter Email Address

Required

When do you plan to enter Southern University? (Month / Year)
Enter Month / Year

Required

Probable Major in College?
Enter Probable Major in College

Required

On CampusOff Campus

Required

Accept

You plan to live

Notes:
- Band membership is open to all university students regardless of their major, sex, religion, or national origin.

- Upon receipt of this application, your name will be placed on our mailing list so that you may receive additional information

regarding audition and pre-band camp.

I, the applicant for this form warrant the truthfulness of the information provided in this application.

I understand that checking this box ( I Accept) constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Additional Links

- Southern University

- Human Jukebox Alumni

Contact Information

P.O. Box 9621,

Baton Rouge, LA 70813

Ph. 225.771.3528

info@humanjukebox.com