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C4A Registration Form: Fall 2017
This form is to register for or receive information about individual lessons, group classes, and performance ensembles at the Community Center for the Arts during the Fall 2017 semester (September through December).

You may enroll for multiple activites on one form. Additional people need a separate form.

You may also enroll for individual lessons during July and August, 2017, with this form.

Email address
Student Information
Student Is
Student First Name
Your answer
Student Last Name
Your answer
Birth Date
Required if Student is under 18
MM
/
DD
/
YYYY
Parent (or Guardian) Information
Parent 1 (Adults: please fill in your own information)
Parent 1 First Name
Your answer
Parent 1 Last Name
Your answer
Parent 1 Email
Your answer
Parent 1 Phone
Your answer
Parent 2
Parent 2 First Name
Your answer
Parent 2 Last Name
Your answer
Parent 2 Email
Your answer
Parent 2 Phone Number
Your answer
Mailing address
Street Address
Your answer
Street Address Line 2
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Individual Lessons
Please tell us what you would like to study. Someone on our staff will contact you to help you get started.
Check All That Apply
Lessons: billed at $23/half hour; $34.50 for 45 minutes; $46 for 60 minutes.
Other Instument
Your answer
If you have already connected with one of our teachers please list that teacher here:
Your answer
Performance Ensembles
Please check boxes below to register for ensembles. You may check as many boxes as you wish. You should already be able to play your instrument to join an ensemble. Please check our website for details.

If you have questions about our ensembles please contact us or visit our website http://c-4a.org/ for more information.

If you don't see what you're looking for it may be listed under "Group Classes" below.

Ensembles for kids: all billed at $150 per semester.
Ensembles for upper teens to adult: all billed at $150 per semester.
What instrument would you like it play in our ensembles? Please check all that apply.
Other Instument
Your answer
Years of Experience playing your instrument
Group Lessons
Please check boxes below to register for group classes.

If you have questions about our group classes please contact us or visit our website for more information.

If you don't see what you're looking for it may be listed under "Ensembles" above.

Group Classes for Absolute beginners, age high school-adult. Billed at $100 per six-week session.
Group Classes for people who already play, age high school to adult. Billed at $100 per six-week session. May be taken multiple times.
Emergency Contact Information
First Name
Your answer
Last Name
Your answer
Relationship
Phone Number
Your answer
Alt Phone Number
Your answer
Does student have any medical conditions, concerns, or modifications we should be aware of? This information will be shared only with relevant C4A staff.

Medical Concerns?
Medical details
Your answer
Finalizing Your Registration
If I am registering for a group class or ensemble, I understand that my registration will not be complete until payment is made in full and that I may forfeit my place if payment is not made. Payment may be made by check or cash. Payment via electronic check or credit card is available through our emailed invoicing. PayPal is available on our website.

If I am registering for lessons, I understand that payments for lessons are due when invoiced, or may be paid in advance. I understand that if my account is more than 30 days past due there may be an interruption in my program until payment is made or a payment plan is established. I understand that lessons cancelled by me with less than 48 hours notice are unexcused absences and may be billed at the regular lesson rate.

Please read and understand the Consent and Acknowledgement and Medical Release and Authorization below and then sign in the Confirmation Area below before submitting this form.

Contact me About
Would you like to receive our newsletters? Please check all that apply.
Required
How did you hear about C4A?
Questions? Comments? Suggestions?
Your answer
Informed Consent and Acknowledgement
I hereby give my approval for my child’s (or my) participation in any and all activities prepared by the Community Center for the Arts during the selected activities(s). In exchange for the acceptance of said student's candidacy by the Community Center for the Arts, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Community Center for the Arts, and all its respective officers, agents, and representatives from any and all liability for injuries to said student arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said student, I hereby waive all claims against the Community Center for the Arts including all instructors, staff, and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Photographs taken during our activities may be used for our promotional purposes without your further consent. We will not publish or release photos that are inappropreate or identify students by name or otherwise reveal their identities.

Students' names may be listed in programs, on CDs or DVDs, or other media. They will not be listed in a way that identifies individuals. Said media will be available to the student and his/her family.

Most activities will take place on C4A premises, but there may be off-site activities that are announced in advance.

Students, their families, and their guests are all responsible for their own safety during participation in our events, whether on or off our premises.

Students, their families, and their guests are all responsible for their own belongings and equipment during participation in our events, whether on or off our premises.

Medical Release and Authorization
As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child* in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Community Center for the Arts and its affiliates including Directors, teachers, staff, and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

*If an adult student, the same release and authorizations apply, with contact attempt being made with designee listed under emergency contacts.

Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Student or Parent or guardian of student may sign by typing name here:
Your answer
A copy of your responses will be emailed to the address you provided.
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