SUMMER WORKSHOP 2013
Please complete this short questionnaire and we will
contact you as soon as possible.
Thank you!
|
* required
|
|
| 1) Parent's Name (if student is under 18) |
(100 characters max) |
|
| *2) Student Name(s) |
(40 characters max) |
|
| *3) Date of Birth |
(20 characters max) |
|
| *4) Email |
(100 characters max) |
|
| *5) Phone Number/Cell Phone Number |
(100 characters max) |
|
| 6) Address |
(100 characters max) |
|
| 7) City |
(100 characters max) |
|
| 8) State |
(100 characters max) |
|
| 9) Zip |
(100 characters max) |
|
| *10) Which Session do you want to attend? |
| [1] Session 1: June 10 - June 30 |
| [2] Session 2: July 8 - July 28 |
| [3] Session 3: August 5 - August 25 |
|
| 11) Do you sing or play a musical instrument? |
(100 characters max) |
|
| *12) What is the best way to contact you? |
| Phone |
| Email |
|
| 13) Are you a returning performer? If so, which production were you in? |
(50 characters max) |
|
*14) Payment of Registration/Tuition:
Tuition for each student is to be paid in full prior to the first day of each program. Additionally, due to the high demand and limited openings for each program, there will be no refunds or tuition given within 30 days of the scheduled session.
BY INITIALING BELOW, I ACKNOWLEDGE AND AGREE TO THE ABOVE TERMS |
(5 characters max) |
|
*15) Media/Photo Release:
I hereby authorize Family Music Centers to have absolute right to copyright, publish and assign photos taken of my child to television spots, videotapes and sound recordings for the promotion of Family Music Centers current and future productions.
By initialing below, I acknowledge and agree to the above terms |
(5 characters max) |
|
*16) Medical Emergency Authorization:
As the parent or court-appointed legal guardian for the child registering, I hereby give my consent to Family Music Centers to obtain all emergency medical or dental care presribed by a licensed physician (M.D.) or dentist (D.D.S.). This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent.
By initialing below, I acknowledge and agree to the above terms. |
(5 characters max) |
|
17) Medical Emergency Authorization:
As the parent or court-appointed legal guardian for the child registering, I hereby give my consent to Family Music Centers to obtain all emergency medical or dental care presribed by a licensed physician (M.D.) or dentist (D.D.S.). This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent.
By initialing below, I acknowledge and agree to the above terms. |
(1000 characters max) |
|
18) Special Needs Information/Instruction:
If your child has any special needs that we should be made aware (i.e. diabetes, autism, food allergies, etc.) please explain in detail below. |
(1000 characters max) |
|
