Homeschool Registration

Creative Genius HOMESCHOOL Registration Form

Arts Enrichment, Tutoring and Counseling
Date

MonthDayYear
Date
Youth's Legal Name

First NameLast Name
Nickname
Birthdate

MonthDayYear
Date
Current Age
Gender
Race/Ethnicity
Current Grade Level
Parent/Guardian Name
Parent/Guardian E-mail
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about this program?
Primary Discipline/Area of Interest
Secondary Discipline/Area of Interest
I am interested in attending the following days:
Please provide any additional information you would like to share.
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
Format: (000) 000-0000.
Do you wish to receive emails regarding programs, events, and offers from The Performance Academy?
The Performance Academy, Inc.

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

Creative Genius HOMESCHOOL Registration Form

The Performance Academy, Inc.