Page to Stage Registration, Sept 21-Nov 23, 2019
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, $12 per class.)
Email address *
Child First and Last Name *
Your answer
Age *
Your answer
Grade in 2019-2020 school year *
Your answer
Additional Child First and Last Name
Your answer
Additional Child Age
Your answer
Additional Child Grade in 2019-2020 school year
Your answer
Parent/Guardian Name(s) *
Your answer
Preferred Phone *
Your answer
Alternate Phone
Your answer
Child Mailing Address *
Your answer
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):
Your answer
List any medical or physical conditions, including allergies, teachers should be aware of:
Your answer
Medication(s)/Dosage(s):
Your answer
Prescribing/treating physician name/Phone number:
Your answer
Other special needs or comments:
Your answer
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. *
Required
Enter your name to indicate your permission. *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy