2024 Spring Semester Registration Form

2024 Spring Semester Registration Form
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Student
Student Information
Student 1 Information

First NameLast Name
Date of Birth

MonthDayYear
Date
Private Lesson Length
Private lesson students are automatically enrolled in a group class.
Tiny Tots

Enroll
Student 2 Information

First NameLast Name
Date of Birth

MonthDayYear
Date
Private Lesson Length
Private lesson students are automatically enrolled in a group class.
Tiny Tots

Enroll
Student 3 Information

First NameLast Name
Date of Birth

MonthDayYear
Date
Private Lesson Length
Private lesson students are automatically enrolled in a group class.
Tiny Tots

Enroll
Student 4 Information

First NameLast Name
Date of Birth

MonthDayYear
Date
Private Lesson Length
Private lesson students are automatically enrolled in a group class.
Tiny Tots

Enroll

Photo Release: I give permission for Verity Baptist Music Academy and Greater Cumberland Baptist Church to use images of my child(ren) in online and print publication including newspapers and Facebook.
Signature

Clear
Policies: I have read and understand the cancelation, additional children, sickness, and the payment agreement policies.
Signature*

Clear
Medical: In the event of a medical emergency and when a contact cannot be made in a timely manner to me and/or the emergency contact listed, I give my permission for my child(ren) to receive appropriate medical attention. In the event of an unforeseen emergency or any accidents, I release Verity Baptist Music Academy, Greater Cumberland Baptist Church, its employees, and volunteers, and all those related to it, from any liability. I have provided emergency contact numbers and am assured that I will be contacted as soon as possible in the event that there is an emergency.
Signature*

Clear
Release: To the fullest extent permitted by law, I release Verity Baptist Music Academy, Greater Cumberland Baptist Church, its trustees, officers, directors, employees, agents, and representatives from any injury, harm, damage, or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Greater Cumberland Baptist Church, its trustees, officers, directors, employees, agents, and representatives from any claims arising out of my minor child’s participation in the activity.
Signature*

Clear
Should be Empty:

2024 Spring Semester Registration Form

Emergency Contact Information

Student Information