Page to Stage Registration, Saturdays, April 18, April 25, May 2, 2020 @ 1-4 pm
Please complete the following registration form and mail your $100 payment to Adam Swartz Puppets: 215 Delaware Rd. Pa Furnace, Pa 16865. (Or, pay as you go, $40 per day.)
Email *
Child First and Last Name *
Age *
Grade in 2019-2020 school year *
Additional Child First and Last Name
Additional Child Age
Additional Child Grade in 2019-2020 school year
Parent/Guardian Name(s) *
Preferred Phone *
Alternate Phone
Child Mailing Address *
During class, we will take photographs for a slideshow to be shown in class only. We also may create video projects during class. These photos and videos may also be used by Adam Swartz Puppets for printed or online promotional material. Class participants will never be identified by full name in photos or videos. Please check the boxes below to indicate your permission.
List anyone else with permission to pick up your child(ren):
List any medical or physical conditions, including allergies, teachers should be aware of:
Prescribing/treating physician name/Phone number:
Other special needs or comments:
By checking this box and entering my name below, I indicate that I permit my child(ren) to participate in Page to Stage class on the above dates. I also authorize any medical treatment in case of an emergency, and agree that I am responsible for the cost of such treatment. I agree to release, hold harmless and indemnify Adam Swartz Puppets and its agents, representatives and employees, from all claims, damages, or other liabilities for injuries to my son/daughter which are not the result of gross negligence, intentional neglect, or willful or wanton conduct by said agents, representatives, or employees. *
Enter your name to indicate your permission. *
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