2016-2017 REGISTRATION FORM FOR TIM MCGOWAN (VOICE

2016-2017 REGISTRATION FORM FOR TIM MCGOWAN (VOICE)
www.leddycenter.org
You must call Tim at 585-447-4654 to schedule a lesson time!
Check for first month’s tuition MADE PAYABLE AND MAILED TO:
Timothy McGowan 34 Manet Road, Chestnut Hill MA 02467
Registration fee ($10) + Recital fee ($10) = $20.00 TOTAL
MADE PAYABLE AND MAILED WITH REGISTRATION FORM TO:
Leddy Center School P.O. Box 929, Epping, NH 03042
CLASS REGISTERING FOR: _________________________________________________________
DAY/TIME: _________________
NAME: __________________________________________________ AGE: _____ DATE OF BIRTH(00/00/0000) __________________
MAILING ADDRESS (STREET NAME, NUMBER/POBOX): ________________________________________________________________
CITY: ______________________________________________________________ STATE: _______ ZIP: ______________________
HOME PHONE: _______________________________________ CELL PHONE: ______________________________________________
EMAIL: __________________________________________________________________________________________________________
The following must be completed if student is under 18 years of age:
Mother/Guardian’s Name: _____________________________________________ Phone
E-Mail Address: _____________________________________________________
Work or Home: ___________________
Cell: ____________________________
Father/Guardian’s Name: ______________________________________________ Phone: Work or Home : ___________________
E-Mail Address: _____________________________________________________
Cell : ____________________________
In case of an emergency, contact: NAME: ________________________________________ PHONE: _________________
Medical Information: Do you/does the student have any medical conditions which could affect your/his/her participation in class?
Please circle : Y / N If yes, what is the condition and what are the symptoms?___________________________________________
Do you/does the student take any medicines which could affect your/his/her participation in class? Please circle : Y / N If yes,
what is the name of the medicine and what are the side effects?___________________________________________________________
Medical Insurance Information: Insurance Carrier:_________________________Policy/Group #:_____________________________
Release/Waiver and Payment Agreement:
I acknowledge that I have enrolled my child in a class, held at Leddy Center for the Performing Arts, Inc. and that I fully understand and appreciate that any
activity which includes motion may cause accidental injury. I have consulted my physician and received assurances from my physician that the physical
activity required of the program for which would be adversely affected by my/his/her participation in this program. I understand that I have/my child has
the right to participate only to the extent I/he/she am/is comfortable, and I/he/she will limit my/his/her conduct accordingly.
Please print, sign and date this form. Registrations are not accepted without signature and date.
Parent/Guardian’s Signature: __________________________________________ Date: _______________
2016-2017 REGISTRATION FORM FOR TIM MCGOWAN (VOICE)
www.leddycenter.org
You must call Tim at 585-447-4654 to schedule a lesson time!
Check for first month’s tuition MADE PAYABLE AND MAILED TO:
Timothy McGowan 34 Manet Road, Chestnut Hill MA 02467
Registration fee ($10) + Recital fee ($10) = $20.00 TOTAL
MADE PAYABLE AND MAILED WITH REGISTRATION FORM TO:
Leddy Center School P.O. Box 929, Epping, NH 03042
I accept responsibility for any injury, physical or emotional, which might arise out of this activity and agree to hold Leddy Center for the Performing Arts,
Inc., harmless for any damages and/or costs, and will reimburse any legal fees, which may be incurred should I make demand or institute suit and be
unsuccessful in any such action. If I am unreachable, or I am/my child is unable to speak in the event of an injury, I grant permission for medical treatment
to be given.
I understand and acknowledge that I am responsible for paying for all lessons whether I/my child attend/s the lesson or not. Furthermore, I fully understand
when tuition payments are due, and will make payment on time or will be assessed a $10.00 late fee per week that payment is late. I also understand that
should I fail to make payment within one week of the due date, I/my child will not be allowed into class until payment has been made in full, including late
fee. Should this happen more than once, I understand that Leddy Center retains the right to re-assess the situation and take additional steps to protect its
teachers, who rely on tuition payments for their income. There are NO REFUNDS- NO EXCHANGES.
I agree to allow Leddy Center to use my likeness, whether in still or moving form, for publicity purposes including, but not limited to, newspaper, internet,
posters and TV advertisements. I hold no contract with another agency or person which would prohibit such usage.
Please print, sign and date this form. Registrations are not accepted without signature and date.
Parent/Guardian’s Signature: __________________________________________ Date: _______________