Name: Lessons Registration
SKU: 5200
Availability: InStock

Student Information
Student Type*
Is your registration information up to date?
Student Name*
First Last
School
Gender*
Preferred Pronouns
Age*
Grade as of 9/1/23*
Date of Birth*
MM slash DD slash YYYY
Do we have your permission to photograph your child in rehearsal or performance to be used as part of our marketing in print or online?*
Do we have your permission to videotape your child in rehearsal or performance to be used as part of our marketing in print or online?*

Emergency Medical information is up to date?*
Medical Issues/History information is up to date?*
Medical Insurance information is up to date?*
Allergy to a medicine, food, plant, animal, or insect toxin
Will your child be carrying a prescribed epi-‐pen?*
EMERGENCY CONTACT INFORMATION
In case of an emergency, we will first try the phone numbers listed on the top of the registration form (parent/guardian). Please list 3 additional contacts if needed.
Emergency Contact*
Full name
Emergency Contact’s Cell Phone*
Relationship to Student*
Emergency Contact*
Full name
Emergency Contact’s Cell Phone*
Relationship to Student*
Emergency Contact*
Full name
Emergency Contact’s Cell Phone*
Relationship to Student*
EMERGENCY MEDICAL INFORMATION
Family Physician*
Phone*
Dentist*
Phone*
MEDICAL ISSUES/ HISTORY
Student has or has history of: (please check all that apply and give details)
Asthma*
ADD/ADHD*
LD (Learning Diability)*
Diabetes*
Insulin*
Seizures*
Headaches/ migraines*
Serious illness/injury*
Contact Lenses*
Any other conditions that may require special care, medication, or diet? Any other concerns?
MEDICAL AUTHORIZATION
I hereby authorize, consent and direct the Creative and Performing Arts Academy of NEPA (CaPAA of NEPA), its directors, officers, and employees, and any physician, hospital, or other health care provider selected by CaPAA of NEPA to take such action as is necessary in the circumstances to provide emergency care and related treatment to my above-‐named child in my absence, should the need arise while he/she is participating in the programs of CaPAA of NEPA and release them from any liability, either personal or as a professional in carrying out that action. I hereby designate CaPAA of NEPA, its directors, officers, and employees as my authorized agent for the signing of any consent forms required by any such health care provider in connection with such health care.
MEDICAL INSURANCE COMPANY*
POLICY HOLDER’S NAME*
INSURANCE COMPANY POLICY NUMBER*
Signature of Parent/Guardian*
Date*
MM slash DD slash YYYY

Lessons Registration

Lessons Registration

Step 1 of 4

Student Information

GENERAL INFORMATION

GENERAL INFORMATION

EMERGENCY CONTACT INFORMATION

EMERGENCY MEDICAL INFORMATION

MEDICAL ISSUES/ HISTORY

MEDICAL AUTHORIZATION