RodneyStreet Private Lesson Sign-Up

Private Lesson Registration

(One form per child)
Private Lessons are available.

One child rate is $30. Multiple children rate is $20 per child.
Practice location and frequency will be determined with instructor.
Participant Information
How many children will be taking lessons?

1234
Child's Name*

First NameLast Name
Child's Age*
Parent/Guardian Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Email*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pick-Up Authorization
- Please list the full names of ALL persons authorized to pick up your child from RodneyStreet Programming. Photo identification will be required from ALL persons.
- In the event of a custody agreement, which prevents a parent or guardian from picking up your child, we must be provided with a copy of legal documentation which states such information/rulings.
- Please keep this list up to date and notify us immediately if you would like to make changes.
- Please notify a staff member in advance, if possible, when someone other than the parent/guardian will be picking up your child.
Please list the individuals that are authorized to pick up your child*
My child is authorized to walk homeMy child is authorized to take public transportation

Emergency Contacts
Please list all emergency contacts*
In the event that I cannot be reached in an emergency, I hereby give my permission to RodneyStreet staff to follow proper Emergency Medical Procedures.
Parent Initials*
Parental Consent
Please select consent given below and sign.*

I give permission to have my child, named above, participate in all RodneyStreet programs/activities – this includes transporting child to/from activities, if necessary.I grant RodneyStreet unrestricted permission to use photographs and/or video and/or voice recordings taken of my child for use in RodneyStreet publications, including web sites or other electronic forms of media. I authorize RodneyStreet, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically. I agree that RodneyStreet may use such photographs of my child, with or without my child’s name, and for any lawful purpose, including, but not limited to, publicity and Web content.I hereby release Rodney Street, its staff, contractors, and volunteers from any responsibility as a result of any injury to the child named above due to participation in Rodney Street activities.
Signature

Clear
Date

MonthDayYear
Date

Communications Consent
I understand that as part of the registration process, either one or both parent/guardians listed in this application will be automatically enrolled to receive RodneyStreet communications. This includes the Remind App (a text based service) that will be used by staff for program communications and emails that will include the RodneyStreet monthly newsletter and general organization informational emails. I agree to be enrolled unless I Opt-out below.

I do not wish to be enrolled in the Remind AppI do not wish to receive the RodneyStreet monthly newsletter

My Products

Private Lesson$30.00

Individual private lesson.

Quantity

Total $0.00

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Private Lessons are available.