Summer at SSC Registration
Student First Name *
Your answer
Student Last Name *
Your answer
Student DOB (Adult students can enter the current date here) *
MM
/
DD
/
YYYY
Parent/Guardian Name *
Your answer
Street Address *
Your answer
Town *
Your answer
Zip Code *
Your answer
Parent email *
Your answer
Student email (or enter N/A) *
Your answer
Parent cell phone (or home phone) *
Your answer
Student cell phone (or enter N/A) *
Your answer
Emergency Contact 1 Name/Phone/Relationship (other than parent) *
Your answer
Emergency Contact 2 Name/Phone/Relationship (other than parent) *
Your answer
Allergies/Medications/Other *
Please list any allergies, medications or other information that effects your child's participation in this program. (enter "none" if N/A)
Your answer
Student T-Shirt Size *
By checking this box, I hereby give permission for my child to receive medical treatment if I cannot be reached. *
Do you give permission for photos and/or video of your child to be taken and possibly used to promote this program? *
By checking this box, I agree to hold harmless South Shore Conservatory, its agents, employees, contractors and volunteers from any and all claims sustained while participating in this program. *
Choose the program you are registering for below: *
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