GLOBAL MUSIC ACADEMY AFTER SCHOOL PROGRAM REGISTRATION FORM (SEPT - JUNE 2013-2014)

  1. Participant Information
  2. Student’s name:
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  3. Date of Birth
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  4. Address:
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  5. City:
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  6. State:
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  7. Zip:
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  8. Home phone:
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  9. Cell phone:
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  10. E-mail address:(*)
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  11. School:
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  12. Grade:
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  13. Parents/ Guardian Information
  14. Mother’s full name:
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  15. Home phone:
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  16. Cell phone:
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  17. Address:
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  18. City:
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  19. State:
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  20. Zip:
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  21. Place of employment:
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  22. Address of employment:
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  23. Work phone:
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  24. E-mail address:
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  25. Father’s full name:
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  26. Home phone:
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  27. Cell phone:
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  28. Address:
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  29. City:
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  30. State:
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  31. Zip:
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  32. Place of employment:
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  33. Address of employment:
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  34. Work phone:
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  35. E-mail address:
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  36. If parent/ guardian can’t be reached please contact:
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  37. Phone :
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  38. Relationship:
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  39. Insurance Information
  40. Insurance Carrier:
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  41. Insurance phone:
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  42. Who carries insurance on participant:
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  43. Allergies, physical conditions,or medical conditions that would limit participation:
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  44. After School Program Prices
  45. The annual tuition for the full time program is prorated to $120 /week. This provides transportation from the school to Global Music Academy, a snack, homework help and performing arts classes.
  46. Full time attendance is 4- 5 days / week
  47. Part times attendance is 2 -3 days / week and the cost depends on the classes that the participant will attend.
  48. Discounts ( check if applies to participant)
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  49. Registration Fee ( non- refundable): $65 paid
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  50. Total weekly tuition:
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  51. Total annual tuition :
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  52. Initials:
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  53. Medical Waiver / Release of responsability
  54. I ACKNOWLEDGE, UNDERSTAND, AND ASSUME ALL RISKS INVOLVED IN ANY ACTIVITIES ON THE PREMISES OF GLOBAL MUSIC ACADEMY INCLUDING BUT NOT LIMITED TO DANCE. I FURTHER AGREE TO HOLD HARMLESS THE OWNERS, STAFF, AND TEACHERS OF GLOBAL MUSIC ACADEMY FROM ANY AND ALL CLAIMS, SUITS, LOSSES, OR DAMAGES OF ANY NATURE WHATSOEVER, INCLUDING BUT NOT LIMITED TO SUCH CLAIMS THAT MAY RESULT FROM MY CHILD'S INJURY OR DEATH, WHETHER IT BE ACCIDENTAL, AS A RESULT OF NEGLIGENCE OR OTHERWISE, DURING OR ARISING IN ANY WAY FROM THE AFTER SCHOOL PROGRAMS. I HEREBY GRANT PERMISSION TO LICENSED HOSPITAL AND/OR STAFF MEMBERS TO ADMINISTER IMMEDIATE MEDICAL TREATMENT AS DEEMED NECESSARY TO MY CHILD SHOULD HE/SHE BE INJURED DURING ANY EVENT WHILE IN THE CARE OF GLOBAL MUSIC ACADEMY STAFF. FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF EXPENSES RELATED TO MY CHILD’S MEDICAL TREATMENT.
  55. Initials:
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  56. Payment Agreement
  57. Credit Card Type:
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  59. Amount:
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  60. Check:
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  61. Cash:
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  62. AND PROCEDURES OF GLOBAL MUSIC ACADEMY, INC. ALL CHECKS ARE TO BE MADE OUT TO GLOBAL MUSIC ACADEMY IN THE AMOUNT INDICATED ABOVE. WEEKLY PAYMENT IS DUE BY MONDAY OF EACH WEEK. IF PAYMENT IS NOT PAID BY WEDNESDAY OF THE WEEK, A $10 LATE FEE WILL BE ASSESSED TO THE STUDENT'S ACCOUNT PER WEEK UNTIL PAID IN FULL. IF THE STUDENT IS PICKED UP AFTER 6:30PM, A $1.00 PER MINUTE LATE FEE WILL BE ADDED TO THE ACCOUNT. ALL LATE FEES NEED TO BE PAID ON THE DAY OF LATE NOTICE. IF THE ACCOUNT IS NOT PAID IN FULL WITHIN 7 DAYS, THE STUDENT WILL BE WITHDRAWN AND FINANCIAL OBLIGATION MUST BE PAID IN FULL BEFORE THE STUDENT IS ALLOWED TO RETURN.
  63. PARENT/GUARDIAN SIGNATURE: (I AGREE TO THIS OBLIGATION OF PAYMENT)
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  64. DATE
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