STUDENT APPLICATION (COMPLETE AND PRINT AND BRING TO THE BUILDING BLOCK SCHOOL FOR THE ARTS)

 

NAME: __________________________________________________   AGE (IF 18 AND YOUNGER): _____

 

PARENT EMAIL (PLEASE PRINT): ___________________________________________

 

STUDENT EMAIL (PLEASE PRINT): __________________________________________

 

ADDRESS: ________________________________________________

 

CITY: ______________________________________________ STATE/ZIP: ______________________

 

PARENT/GUARDIAN NAME: ___________________________________________________________

 

PHONE: _____________________________________   CELL: ________________________________

 

EMERGENCY CONTACT NAME: __________________________________PHONE: __________________

 

ALLERGIES/MEDICAL CONDITIONS? ________________________________________________________

 

ARE YOU INTERESTED IN (CHECK ALL THAT APPLY):

TALENT REPRESENTATION ______           COMMERCIAL,TV OR PRINT WORK __________

VOLUNTEER FOR EVENTS, ETC _______                 ELECTRONIC NEWSLETTER ___________

CLASSES

1.       _________________________________________ DAY ________ TIME __________

 

2.       _________________________________________ DAY ________ TIME __________

 

3.       _________________________________________ DAY ________ TIME __________

 

4.       _________________________________________ DAY ________ TIME __________

 

FOR OFFICE USE

TOTAL HOURS ___________ PACKAGE_____________ REGISTRATION FEE ____________

DISCOUNTS ________________   BALANCE _______________________

PAYMENT PLAN: SEMESTER         MONTHLY           ½ SEMESTER

PARTICIPATION AND MEDIA

In consideration of ______________________________________ (student name) being permitted to participate in classes, workshops, offsite events or performances, by signing below, I release The Building Block School for the Arts, LLC from any and all liability for any and all loss and damage, on account for any injury or loss suffered by the participant.  I expressly agree that this release is intended to be as broad and inclusive as permitted by the laws of the State of Tennessee and that if any portion is held invalid, that the balance shall continue in fully legal effect.  I give permission for the use of the student/my image in all media and advertising used by the Building Block School for the Arts, LLC.

MEDICAL AUTHORIZATION

Are there any medical conditions the faculty or staff need to be answer of?  Please discuss in detail with Sherry Johnson or Susan Manning prior to the start of classes.

Permission is hereby granted to transport above named participant to a doctor or hospital in case of emergency due to illness or injury when unable to locate parent/legal guardian.

Name of Physician: __________________________________________________

Insurance Policy and Number: _____________________________________

Emergency Contact: ______________________________________ Home/Cell: _______________

Relationship to student: ___________________________