Long Grove Performing Arts Academy, 2017 Summer Session Registration
Email address *
Class & Lesson Pre-Registration
Please select all lessons and classes for which you are enrolling, to register, simply fill out this form. If you are a new student please add the one-time $25 enrollment fee. Please call 847.780.SING with any questions. Thank you!
Student's First Name *
Your answer
Student's Last Name *
Your answer
1st - Parent/Guardian's Name (if under 18)
Your answer
2nd - Parent/Guardian's Name (if under 18)
Your answer
Student's Date of Birth *
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Street Address *
Your answer
Street Address Street Address Line 2
Your answer
City *
Your answer
State *
Your answer
Postal / Zip Code *
Your answer
Student's E-mail *
Your answer
Parent E-mail (If student is over 18 yrs please enter your email address again.) *
Your answer
Student's Home Phone Number *
Your answer
Students Cell Phone Number
Your answer
1st - Parent/Guardian's Name Cell Phone Number *
Your answer
2nd - Parent/Guardian's Name Cell Phone Number *
Your answer
When is the best time to call? *
What is the best phone number to call? *
Emergency and Medical Information
As Parent/Guardian I hereby give Long Grove Preforming Arts Academy staff permission to see that my minor/child receives medical treatment in an emergency. * *
Liability/Photo/Video Release
I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered student to attend the Long Grove Performing Arts Academy and consent to its Policy.

I furthermore understand the Long Grove Performing Arts Academy often takes photographs or videos of participants during its classes, lessons, events and recitals. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of the Long Grove Performing Arts Academy. The Long Grove Performing Arts Academy will not identify me or my child by name, or release any other personal information without additional written permission from me.

Electronic Signature: By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.) *
Your answer
Relationship to registered student *
Your answer
Current Date *
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Time *
Time
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Registering For The Following:
Private Lessons *
Required
Acting, Music & Movement Classes *
Required
Choose Your Payment Method
Payment Options *
A copy of your responses will be emailed to the address you provided.
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