25/26 CREATIVE GENIUS® Free AfterSchool Program Registration

CREATIVE GENIUS® Registration Form

Free AfterSchool Arts Education & Technology program formerly known as "Squad Goals." Classes begin 08/18/25 Ages 12-18
Date

MonthDayYear
Date
Youth 12 years old before May 31, 2026 OR in the 6th Grade?
This is calculated & for admin purposes.
Youth's Legal Name*

First NameLast Name
Nickname
Birthdate*

MonthDayYear
Date
Current Age
Ages 12-18 (unless turning 12 before May 31st, 2026)*
Gender (at Birth)
Race/Ethnicity*
Last 4 of SSN*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How will the youth attend Creative Genius?*

TPA Campus (3674 Beach Blvd.)Off-Site (ex: A school, church, or other community location)
Outbound Location
School Name*
Current Grade Level*
Current Grade Level*
Student ID (Numbers Only. Do not include the 'S'. Enter 9999999 if homeschooled)*
Parent/Guardian Name*
Parent/Guardian E-mail *
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
How did you hear about this program?
#Creative Genius® Formerly Squad Goals
This program is available every day Monday through Friday. Participants must commit to a minimum of two (2) days a week, but can select as many as five (5).

Class sizes are limited and attendance is important.
Primary Discipline/Area of Interest *
Secondary Discipline/Area of Interest *
I am interested in attending the following days (Must pick at least 2):*

Monday 3:00PM - 6:00PMTuesday 3:00PM - 6:00PMWednesday 3:00PM - 6:00PMThursday 3:00PM - 6:00PMFriday 3:00PM - 6:00PM
List medications the youth is prescribed including dosage and frequency. (Type 'NA' if question does not apply.)*
Youth's dietary restrictions. (Type 'NA' if question does not apply.)*
List any allergies the youth may have. (Type 'NA' if question does not apply.)*
Does the youth have a history of running away?*

YesNo
How does the youth get along with peers? Are there any social concerns? *
Does your child have a history of any mental health needs?*

YesNo
Please provide details.
Consent & Release of Liability Waiver

I am signing this Parental Consent Form and Release of Liability Waiver for the purpose of authorizing the above named student’s participation in the enrichment activities, and provision of meals by staff and volunteers associated with the above program. I acknowledge that this is a voluntary activity for which I freely give permission for my child’s participation.

I further give my consent for my child to be photographed or videotaped during the activities involved in this learning experience and grant permission to The Performance Academy to use said photos or videos for promotional and/or educational purposes. Said consent is given without any expectation of compensation or reward for any photos taken and/or used in educational and promotional literature.

By signing below, I attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.
Parent/Guardian's Legal Name*

FirstLast
Your Relationship to Youth Applicant*
Emergency Contact Name*
This is the person who should be responsible for taking any incident reports regarding youth or to pick up youth if absolutely necessary.
Emergency Contact Number*
Do you wish to receive emails regarding programs, events, and offers from The Performance Academy?*

YesNo
The Performance Academy, Inc.

3674 Beach Blvd, Jacksonville, Florida. 32207
Should be Empty:

CREATIVE GENIUS® Registration Form

The Performance Academy, Inc.