Learning Pod Registration

Choose Your Days *

Monday

Tuesday

Wednesday

Thursday

Friday

Student Full Name *

First Name

Last Name

Student Birthdate *

MM

DD

YYYY

Student Home Phone *

(###)

###

####

Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Full Name *

First Name

Last Name

Cell/Work Phone *

(###)

###

####

Address if Different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact (other than the person listed in registration section) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Does the student have any medical conditions of which we should be aware? *

Yes

No

Does the student have any allergies? *

Yes

No

Does the student take any medications regularly? *

Yes

No

Release *

I hereby release and forever discharge owners, instructors, staff, guests, other participants and any and all other parties of liability for any claims, demands, actions and causes of action of every name and nature which I have upon or against owners, instructors, staff, guests, other participants and any and all other parties, including especially claims arising out of any and all personal injuries, damages, expenses and any loss or damage whatsoever, resulting to or from my participation in the Boss Academy of Performing Arts Learning and Activity Pod.

Yes

Digital Signature *

First Name

Last Name

Date of Signature *

MM

DD

YYYY