26/27 CREATIVE GENIUS® Free AfterSchool Program Registration

CREATIVE GENIUS® Registration Form

AfterSchool Arts Education & Technology program. Classes begin 08/17/2026
Date

MonthDayYear
Date
Residential Address for all Youth being Registered

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth's Legal Name

First NameLast Name
Nickname
Is this Youth 12 years old before May 31, 2027 OR in the 6th Grade?
This is calculated & for admin purposes.
Birthdate

MonthDayYear
Date
Current Age
Ages 12-18 (unless turning 12 before May 31st, 2026)
Gender (at Birth)
Race/Ethnicity
Last 4 of SSN
Is Youth #1 a returning participant?
Your Relationship to this Youth Applicant
How will this Youth attend Creative Genius?
Outbound Location
School Name
Current Grade Level
Current Grade Level
Student ID (Numbers Only. Do not include the 'S'. Enter 9999999 if homeschooled)
#Creative Genius®
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). Arts areas begin at 4:00, but students may come as early as 2:30.

Class sizes are limited and attendance is important.
Primary Discipline/Area of Interest
Secondary Discipline/Area of Interest
This youth is interested in attending the following days (Must pick at least 2):
List medications this 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 this youth have a history of running away?
How does the youth get along with peers? Are there any social concerns?
Does your child have a history of any mental health needs?
Does your child receive mental health services?
Please provide details.
Do you have a 2nd Youth to register?
2nd Youth's Legal Name

First NameLast Name
Nickname
Is this Youth 12 years old before May 31, 2027 OR in the 6th Grade?
This is calculated & for admin purposes.
2nd Youth's Birthdate

MonthDayYear
Date
Current Age
Ages 12-18 (unless turning 12 before May 31st, 2026)
Gender (at Birth)
Race/Ethnicity
Last 4 of SSN
Is Youth #2 a returning participant?
Your Relationship to the 2nd Youth Applicant
How will the 2nd Youth attend Creative Genius?
Outbound Location
School Name
Current Grade Level
2nd Youth's Current Grade Level
Student ID (Numbers Only. Do not include the 'S'. Enter 9999999 if homeschooled)
#Creative Genius®
This program is available every day Monday through Friday. Students may arrive as early as 2:30. Arts Instruction begins at 4:00. 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
This youth is interested in attending the following days (Must pick at least 2):
List medications this 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 2nd youth may have. (Type 'NA' if question does not apply.)
Does the 2nd youth have a history of running away?
How does the youth get along with peers? Are there any social concerns?
Does your child have a history of any mental health needs?
Does your child receive mental health services?
Please provide details.
Do you have a 3rd Youth to register?
3rd Youth's Legal Name

First NameLast Name
Nickname
Is this Youth 12 years old before May 31, 2027 OR in the 6th Grade?
This is calculated & for admin purposes.
3rd Youth's Birthdate

MonthDayYear
Date
Current Age
Ages 12-18 (unless turning 12 before May 31st, 2026)
Gender (at Birth)
Race/Ethnicity
Last 4 of SSN
Is Youth #3 a returning participant?
Your Relationship to the 3rd Youth Applicant
How will the 3rd Youth attend Creative Genius?
Outbound Location
School Name
Current Grade Level
3rd Youth's Current Grade Level
Student ID (Numbers Only. Do not include the 'S'. Enter 9999999 if homeschooled)
#Creative Genius®
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
The 3rd Youth is interested in attending the following days (Must pick at least 2):
List medications this 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 3rd youth have a history of running away?
How does the youth get along with peers? Are there any social concerns?
Does your child have a history of any mental health needs?
Does your child receive mental health services?
Please provide details.
Do you have a 4th Youth to register?
4th Youth's Legal Name

First NameLast Name
Nickname
Is this Youth 12 years old before May 31, 2027 OR in the 6th Grade?
This is calculated & for admin purposes.
4th Youth's Birthdate

MonthDayYear
Date
Current Age
Ages 12-18 (unless turning 12 before May 31st, 2026)
Gender (at Birth)
Race/Ethnicity
Last 4 of SSN
Is Youth #4 a returning participant?
Your Relationship to the 4th Youth Applicant
How will the 4th Youth attend Creative Genius?
Outbound Location
School Name
Current Grade Level
4th Youth's Current Grade Level
Student ID (Numbers Only. Do not include the 'S'. Enter 9999999 if homeschooled)
#Creative Genius®
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
The 4th Youth is interested in attending the following days (Must pick at least 2):
List medications this 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 4th youth have a history of running away?
How does the youth get along with peers? Are there any social concerns?
Do they have a history of any mental health needs?
Does your child receive mental health services?
Please provide details.

Parent/Guardian Name
How did you hear about this program?
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.

I grant permission for my child to receive emotional support services while attending The Performance Academy. These services may include individual or group talk therapy sessions provided by licensed counselors or supervised counseling interns on-site. I understand that participation in these services is voluntary and focused on supporting my child's emotional well-being in a safe and confidential setting. If a recommendation is made by the counselors for continued support, I agree for the licensed counselor to contact me to coordinate continued care based on the assessment. I will provide the support team will any critical information about my child’s mental wellness.

I understand all staff with The Performance Academy are mandated reporters and required to contact the Department of Children and Families if there are any concerns related to self-harm or harm of another individual. The Performance Academy therapy support team will be happy to walk you through this process if it becomes necessary.

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
Parent/Guardian E-mail
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact's Name
This is an alternate person who should be responsible for taking any incident reports regarding youth or to pick up youth if absolutely necessary.
Emergency Contact's Number
Format: (000) 000-0000.
Total Number of Non-Returning Participants

My Products

Registration Fee

Registration for all first-time registrants.

$25.00 Quantity

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

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® Registration Form

My Products

Payment Methods

The Performance Academy, Inc.