Name: Program Registration
SKU: 5188
Availability: InStock

Program Registration

"*" indicates required fields

Step 1 of 4

Student Information

Student Name*

First Last

T Shirt Size*

School

Gender*

Preferred pronoun

Age*

Grade as of 9/1/23*

Date of Birth*

If a friend referred you to CaPAA, please state their name here:

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*

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Program Registration