Section 2 - Course Registration


Please Print 


Course Code                                          Cost

_________________              $ _______________

_________________              $ _______________

_________________              $ _______________

_________________              $ _______________

_________________              $ _______________

_________________              $ _______________

_________________              $ _______________

_________________              $ _______________      

     Registration  Fee                $            20.00_____

                           Total             $ _______________


Section 3 - Student Information


Print


Student Name: Last  _____________________________________First ___________________________

 Address: _________________________________________________ ____________________________

 City:  _____________________________       State:_____________     Zip Code: _________________

 School District: _________________________________________________Grade Level: ___________

 Birth Date: ___________________ Age: _______

 Parent/Guardian:

Last Name ___________________________________________________First: ____________________

 Phone: (D) (_ _ _) _ _ _ - _ _ _ _    €  (_ _ _) _ _ _ - _ _ _ _         (C) (_ _ _) _ _ _ - _ _ _ _

 Parent/Guardian Email: _________________________________________________

 Second Email (optional): ________________________________________________

 Emergency Contact if Parent/Guardian is unavailable:

 Name: _____________________________________________Relationship: _____________

Phone (D) _ _ _-_ _ _ - _ _ _ _  (E) _ _ _- _ _ _ - _ _ _ _  (C) _ _ _- _ _ _ - _ _ _ _

 
Select Payment

 ____ Credit Card       ____Check (Payable to BCPA)       ____Cash

 Credit Card Type  ____ Master Card   ____Visa   ____AE  

 Credit Card # _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _            Exp. Date_ _ / _ _

 CVV _ _ _       Zip Code __________



________________________________________________________________________________________________________

For BCPA Staff Use Only


Date Received: ____________          Date Entered:  _____________             

Staff INT. Received:  _______          Staff INT. Entered:  __________

 

​​​Please Complete And Return  - 3 Sections


 Section 1 - Release Form

The undersigned, The BCPA student (and his or her parents or guardian if the student is a minor) hereby unconditionally releases and forever discharges BCPA, BCPA employees and agents from any and all damages, cost liabilities, obligations and claims whether arising from BCPA negligence or otherwise and of other injury of any kind, which may be sustained during or by reason of enrollment for study at the studio from this date through August 2018.

 Print

 Date: ____________________

 Parent/Guardian: __________________________________________________________  

 Student: _________________________________________________________________

 Does the student have a medical condition (diabetes, asthma, etc.) ___ Yes ___ No

If yes, please list the condition (s) and give the details so we can recognize any problems that may occur.

__________________________________________________________________________

__________________________________________________________________________

 Will the student be taking any prescription drugs while at the studio? ___ Yes ___ No

If yes, please list by name:

______________________________________________________________________________

______________________________________________________________________________

 
IT IS IMPORTANT THAT YOU FULLY UNDERSTAND THE FOLLOWING INFORMATION

 Some of the activities engaged in at BCPA are physically strenuous and only students who are medically able to participate should do so. Regardless of the cause, the student (or parents or guardian) assumes full responsibility for all risks of accident and personal injury that may result from participation in activities.  BCPA assumes no responsibility or liability with respect to the student’s use of its facilities due to deficiencies in his or her physical health.

BCPA Staff and Faculty reserves the right to dismiss or otherwise discipline any person whose behavior is not acceptable or endangers the safety of themselves or others. Unacceptable behavior includes verbal harassment, physical assault or sexual abuse and the use or possession of alcohol. The use, purchase or sale of any illegal substances at BCPA is strictly forbidden and will not be tolerated. If anyone is involved in any activity associated with these substances or devices, the appropriate law enforcement agency will be contacted to deal with the situation. No refunds will be made in the event of such disciplinary action. Costs incurred by BCPA in a disciplinary action will be the responsibility of the participant, Parent or Guardian.

BCPA retains the right to use any recorded photo or video procured at BCPA or at a BCPA Event for use of publication in print, video, TV and BCPA website.

The Undersigned has read the Release and attached rules, fully understands it and agrees to be legally bound by it and the rules of BCPA.

 Signature Required:

 Parent/Guardian: _____________________________________________ Date: ______________

       

The Butler Center for the Performing Arts​