Registration Form

Student Name*

First NameLast Name

Parent/Guardian Name*

First NameLast Name

Student's Date of Birth*

Date

Email*

example@example.com

Student Gender*

MaleFemale

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School Attending and Grade

Medical Information*

List any medical conditions, allergies, limitations, behavioral concerns. If none, enter NA.

Emergency Contact
First Name* Last Name* Relationship* Phone Number*

Medical Release

I understand that in the case of an accident requiring medical treatment, I authorize my child to receive such treatment as the attending personnel deem appropriate.

Liability Waiver

As the parent or legal guardian of the student listed above, I hereby authorize my child to participate in Flagler Performing Arts Academy's courses and offerings. I agree not to hold the Flagler Performing Arts Academy (FPAA) or persons acting on its behalf responsible for any injuries suffered by my child during activities sponsored by the FPAA, including claims that I or my family might have stemming from negligence of FPAA, its agents, or employees. I hereby waive and release all rights and claims to damage against the FPAA or the facilities being utilized for instruction and events, and agree to indemnify and save and hold harmless FPAA from any loss, liability, damage, or cost that may occur to my child or property.

Photo/Media Release

I grant full permission to Flagler Performing Arts Academy to take and use photographs, images, or recordings of my child, listed above, for informational, educational, and publicity purposes in print or online.

Registration Fee

I understand that the $25 registration fee is a non-refundable administrative fee.

My Products

Registration Fee (non refundable)This fee is per semester and is charged per registration form.

$25.00

Let's Put On A Play! (Amelia Earhart) Product Image

Let's Put On A Play! (Amelia Earhart)Audition Required, Tuition $300, Ages: 11-18, Time 4-6 pm, PCCC, Dates: 11/18 (free audition), 1/6, 13, 20, 2/3, 10, 17, 24, 3/3 Dress Rehearsal 3/6, Show 3/7 (5-8pm) Led by: Miss Ysa

$300.00

Audition Prep CourseGet audition-ready with this fun and focused course designed to help performers shine! Tuition $120, Ages: 8-18, 4-6pm, at PCCC, 3/24, 3/31, 4/7,4/14 Led by: Miss Ysa

$120.00 Quantity
Item subtotal:$0.00

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Total

$0.00

Signature is for above waivers, releases, and fee recognition

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