Student Registration

Carmouche Performing Arts Academy Student Registration

Last Name

First Name

Date of Birth

Month Day Year

Student Email Address

Grade

Current Residence Information

Street Address

City

State

Zip Code

Student Cell Phone Number

Parent/Guardian Residence Information(if different from above)

Street Address

City

State

Zip Code

Emergency Contact 1

Last Name

First Name

Primary Phone Number

Secondary Phone Number

Emergency Contact 2

Last Name

First Name

Primary Phone Number

Secondary Phone Number

Physician and Medical Information

Last Name

First Name

Primary Phone Number

Secondary Phone Number

Preferred Hospital

Insurance/Health Coverage (Company)

Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.

Student Interest (Instrument, Letter Carrier, Drill Team)

I agree to allow my child to participate and be an active member of the Carmouche Performing Arts Academy. I declare that my child is in good physical condition and has no ailments that would prevent participation in the program. I understand that my child’s participation in the performing arts program offered by the Carmouche Performing Arts Academy may involve strenuous physical exertion. I acknowledge that injuries or other complications associated with exercise or physical activity may result from my child’s participation. In exchange for permission for my child to participate in the program, I knowingly agree to waive and release from any and all claims and causes of action that I may acquire against the Carmouche Performing Arts Academy, Todrick Carmouche, trustees, officers, employees, or agents thereof for any and all injuries, loss or damage which my child may suffer or which are in any way connected with my child’s participation in the program. I further agree that my child can be photographed and/or video/audio-taped by Carmouche Performing Arts Academy staff or their designee and for those photos and/or videos to be used for the advertising and promotion of Carmouche Performing Arts Academy programs. I hereby forever release and discharge the Carmouche Performing Arts Academy from any and all claims, actions and demands arising out of or in connection with the use of said photographs or videos, including, without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefit of the assigns, licensees and legal representatives of the Carmouche Performing Arts Academy.

Please sign.