Mainstage Center for the Arts
Let's Make a Show - Over the Rainbow
Registration is quick and easy. Complete the form below and continue to the payment page to pay with a credit card. You can also print the completed form and mail it to: Mainstage Center for the Arts, 27 S. Black Horse Pike, Blackwood, NJ 08012.
Information
Items with an * are required.
Student Name
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First
Last
Guardian Name
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First
Last
Age:
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PREFERRED PRONOUN
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Please Choose
he/him
she/her
they/them
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
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Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
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Bouvet Island
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British Virgin Islands
Brunei
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Burundi
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Cayman Islands
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Chad
Chile
China
Christmas Island
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Libya
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Lithuania
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Madagascar
Malawi
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Mali
Malta
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Montenegro
Montserrat
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Somalia
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Sweden
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Country
Parent's Cell
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Additional Emergency Contact Cell
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Guardian Email #1
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Guardian E-mail #2
Programs and Payment
Let's Make a Show is a 6 week program, 1 hour per week on Tuesdays from Oct. 5 - Nov. 6 with a final performance on Nov. 6th. The price is $65.
Please check one
I would like to register for the 1:00 - 2:00 program for 5 to 8 year olds.
I would like to register for the 2:00 - 3:00 program for 9 - 12 year olds.
EMERGENCY INFORMATION
A description of the section goes here.
In case of an emergency, and guardians can not be reached, please call.
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Relationship to family
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Emergency Contact #:
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Name of Doctor
Doctor's Phone #
Hospital Preference
Insurance Carrier and number
Allergies
*
Medications
Pertinent Information you feel we should have to help insure your child's safety.
Parent of Guardian Signature
*
Privacy Photo Release
Please be advised that by its nature, a stage production will have photos taken by Mainstage and perhaps media outlets. We can assure you, however, that Mainstage will not associate an image of you or your child with their name, unless we have permission from you to do so. I grant Mainstage Center for the Arts and their representatives the right to use my Child's photographs or photographs of myself, and videos taken during classes, rehearsals, and productions during the 2020/21 season. I authorize Mainstage Center for the Arts to use and publish the same in print and/or electronically. I agree that Mainstage Center for the Arts may use such photographs and video without my name attached, and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, social media, and Web content.
Studio Classes at Mainstage Center for the Arts
I hereby irrevocably release and forever discharge Mainstage Center for the Arts, its trustees, employees, agents, successors and assigns, and representatives from all and any liability by the taking/or publishing of any photograph, video tape, record, interview, statement or image of me or my child, as authorized in this consent form.
I warrant that I am of full age and have every right to contract in my own or my child’s name and that I am fully familiar with the contents of this authorization and consent.
By placing a check mark below this authorization and consent form, I hereby waive any right to compensation for the stated uses and I acknowledge that I have read and understand the above and agree to the terms of this Consent and Release
*
I have read and agree to the terms of this release.
RETURNED CHECK POLICY: ALL CHECKS RETURNED BY YOUR BANK WILL BE SUBJECT TO A $35 RETURN CHECK
CHARGE. RETURNED CHECKS MUST BE REPLACED WITH A CERTIFIED CHECK, CASHIERS CHECK OR MONEY ORDER AND MUST INCLUDE THE ADDITIONAL CHARGE.
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