Studio /Outreach Registration Form
School _______________________ Date_____________
Student Name ______________________________ Birth date _________Grade ____
Class 1_________________ Class 2 __________________
Student Name ______________________________ Birth date _________Grade ____
Class 1_________________ Activity/Class 2 ___________________
Parent/ Name_____________________________________________________________
Complete Address ________________________________________________________
Phone________________________Email______________________________________
Shirt Size ________ Skirt Size _________ Pants Size __________
How did you hear about Journey? ______________________________
Special Education Y N
Food Allergies/Restrictions ________________________________________________
Medical Conditions/Considerations___________________________________________
Child Physician or Clinic Name___________________________phone #____________
Emergency Contact _____________________________phone #___________________
Authorized alternate pick-up
________________________________________________________________________
________________________________________________________________________
Office Use Only
Payment Option ____________________________
Tuition Total ________
Costume Total ________
-Scholarship Total ________
-Discount /Gift certificate Total _________
Grand Total ___________
*$15 monthly late fee $35 return check fee
By signing below, I am indicating that I have read and understand the JPAC/JAS Policies & Procedures for
the current
semester. I am aware that I can access these policies at www.journeyartscenter.org. I am aware of all
payments
and fees associated with this registration and agree to all of the terms and conditions. I understand that by
registering
for classes at Journey Performing Arts Center that I am responsible for tuition for the entire session
regardless of
absence.
Cancellation I can cancel this agreement in writing on or before ____________________ to receive a
prorated refund
minus any discount, concessions or scholarships
_________________________________________
_______________________________________________
Parent/Guardian Name Parent/Guardian Signature & Date
School _______________________ Date_____________
Student Name ______________________________ Birth date _________Grade ____
Class 1_________________ Class 2 __________________
Student Name ______________________________ Birth date _________Grade ____
Class 1_________________ Activity/Class 2 ___________________
Parent/ Name_____________________________________________________________
Complete Address ________________________________________________________
Phone________________________Email______________________________________
Shirt Size ________ Skirt Size _________ Pants Size __________
How did you hear about Journey? ______________________________
Special Education Y N
Food Allergies/Restrictions ________________________________________________
Medical Conditions/Considerations___________________________________________
Child Physician or Clinic Name___________________________phone #____________
Emergency Contact _____________________________phone #___________________
Authorized alternate pick-up
________________________________________________________________________
________________________________________________________________________
Office Use Only
Payment Option ____________________________
Tuition Total ________
Costume Total ________
-Scholarship Total ________
-Discount /Gift certificate Total _________
Grand Total ___________
*$15 monthly late fee $35 return check fee
By signing below, I am indicating that I have read and understand the JPAC/JAS Policies & Procedures for
the current
semester. I am aware that I can access these policies at www.journeyartscenter.org. I am aware of all
payments
and fees associated with this registration and agree to all of the terms and conditions. I understand that by
registering
for classes at Journey Performing Arts Center that I am responsible for tuition for the entire session
regardless of
absence.
Cancellation I can cancel this agreement in writing on or before ____________________ to receive a
prorated refund
minus any discount, concessions or scholarships
_________________________________________
_______________________________________________
Parent/Guardian Name Parent/Guardian Signature & Date
Release, Waiver of Liability & Indemnity Agreement
In consideration of being permitted to participate in any way in the Journey Performing Arts Center and Journey
After School Programs and/or being permitted to enter for any purpose any restricted area (here in defined as
any area where in admittance to the general public is prohibited), the parent(s) and/or legal guardians) of the
minor participant named below agree:
I understand that I have the option inspecting all facilities related to the program.
I/WE fully understand and acknowledge that
(a) There an: risks and dangers associated with participation in Dance events and activities which could
result in bodily injury partial and/or total disability, paralysis and death.
(b) The social and economic losses and/or damages, which could result from these risks and dangers
described above, could be ~.
(c) These risks and dangers may be caused by the action, inaction or negligence of the participant or
the action, inaction or negligence of others, including, but not limited to, the Releases named below.
(d) There may be other risks not known to us or an: not reasonably foreseeable at his time.
I/WE accept such risks and responsibility for the losses and/or damages following such injury, disability,
paralysis or death, caused, whether caused in whole or in part by the negligence of the Releases named below.
I/WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the dance facility,
company used by the participant, including its owners, managers, promoters, lessees of premises used to conduct
the dance event or program, premises and event inspectors, underwriters, consultants and others who give
recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the
dance facility or events held at such facility and each of them, their directors, officers, agents, employees, all for
the purposes herein referred to as "Release" ... FROM ALL LIABILITY TO THE UNDERSIGNED, my/our
personal representatives, assigns, executors, heir's and next to kin FOR ANY AND ALL CLAIMS, DEMANDS.
LOSSES OR DAMAGES AND ANY CLAIMS OR DEMANDS THEREFORE ON ACCOUNT OF ANY
INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF THE PARTICIPANT OR DAMAGE TO
PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR ALLEGED TO BE
CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASE OR OTHERWISE.
Minor Photo Release
In consideration of the minor named below as a student of Journey Performing Arts Center/ Journey After School, and
for other good and valuable consideration herein acknowledged as received, upon the terms hereinafter stated, I
hereby
grant to Journey Performing Arts Center, Inc , and those acting with its authority and permission, the absolute right
and
permission to copyright and use, re-use, publish, and re-publish
photographic portraits, pictures, or videos of the minor or in which the minor may be included, in whole or in part, in
conjunction with the minor's own or a fictitious name, or reproductions thereof in color or otherwise, made through any
medium at his/her studios or elsewhere, and in any and all media now or hereafter known, for art, advertising trade or
any other purpose whatsoever. I also consent to the use of any printed matter in conjunction therewith, including but
not limited to fliers, website, newspaper, ect.
I hereby waive any right to compensation or the right to final inspection of printed materials that may be used in
connection therewith.
I hereby warrant that I am of full age and have every right to contract for the minor in the above regard.
I HAVE READ THIS PHOTO RELEASE AND WAIVER OF LIABILITY, ASSUMPTI0N OF RISK AND
INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE
GIVEN UP RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY
WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND
MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE
GREATEST EXTENT ALLOWED BY LAW.
_______________________________________
Student Name
_________________________________________ _______________________________________________
Parent/Guardian
In consideration of being permitted to participate in any way in the Journey Performing Arts Center and Journey
After School Programs and/or being permitted to enter for any purpose any restricted area (here in defined as
any area where in admittance to the general public is prohibited), the parent(s) and/or legal guardians) of the
minor participant named below agree:
I understand that I have the option inspecting all facilities related to the program.
I/WE fully understand and acknowledge that
(a) There an: risks and dangers associated with participation in Dance events and activities which could
result in bodily injury partial and/or total disability, paralysis and death.
(b) The social and economic losses and/or damages, which could result from these risks and dangers
described above, could be ~.
(c) These risks and dangers may be caused by the action, inaction or negligence of the participant or
the action, inaction or negligence of others, including, but not limited to, the Releases named below.
(d) There may be other risks not known to us or an: not reasonably foreseeable at his time.
I/WE accept such risks and responsibility for the losses and/or damages following such injury, disability,
paralysis or death, caused, whether caused in whole or in part by the negligence of the Releases named below.
I/WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the dance facility,
company used by the participant, including its owners, managers, promoters, lessees of premises used to conduct
the dance event or program, premises and event inspectors, underwriters, consultants and others who give
recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the
dance facility or events held at such facility and each of them, their directors, officers, agents, employees, all for
the purposes herein referred to as "Release" ... FROM ALL LIABILITY TO THE UNDERSIGNED, my/our
personal representatives, assigns, executors, heir's and next to kin FOR ANY AND ALL CLAIMS, DEMANDS.
LOSSES OR DAMAGES AND ANY CLAIMS OR DEMANDS THEREFORE ON ACCOUNT OF ANY
INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF THE PARTICIPANT OR DAMAGE TO
PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR ALLEGED TO BE
CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASE OR OTHERWISE.
Minor Photo Release
In consideration of the minor named below as a student of Journey Performing Arts Center/ Journey After School, and
for other good and valuable consideration herein acknowledged as received, upon the terms hereinafter stated, I
hereby
grant to Journey Performing Arts Center, Inc , and those acting with its authority and permission, the absolute right
and
permission to copyright and use, re-use, publish, and re-publish
photographic portraits, pictures, or videos of the minor or in which the minor may be included, in whole or in part, in
conjunction with the minor's own or a fictitious name, or reproductions thereof in color or otherwise, made through any
medium at his/her studios or elsewhere, and in any and all media now or hereafter known, for art, advertising trade or
any other purpose whatsoever. I also consent to the use of any printed matter in conjunction therewith, including but
not limited to fliers, website, newspaper, ect.
I hereby waive any right to compensation or the right to final inspection of printed materials that may be used in
connection therewith.
I hereby warrant that I am of full age and have every right to contract for the minor in the above regard.
I HAVE READ THIS PHOTO RELEASE AND WAIVER OF LIABILITY, ASSUMPTI0N OF RISK AND
INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE
GIVEN UP RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY
WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND
MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE
GREATEST EXTENT ALLOWED BY LAW.
_______________________________________
Student Name
_________________________________________ _______________________________________________
Parent/Guardian
Monthly Automatic Debit Consent Form
Name on Account:___________________________________________________________
Student’s Name:_____________________________________________________________
Address:___________________________________________________________________
City:___________________________________ Zip: _____________________________
Home Phone:_______________________ Alternate Phone:__________________________
Email:_______________________________________________________________________
Please Circle:
VISA MasterCard Amex Discover
Credit Card/Debit Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: __ __ / __ __
CVI# Located on back:__ __ __
Please read and sign the following agreement:
With my signature below, I authorize Journey Performing Arts Center, Inc. or its assignees to debit the
account referenced above. I understand that my account will automatically be charged on the 25th day of
each month for the amount equal to the remaining balance on my account for the corresponding month. I
authorize these monthly debits between the dates of _______ and ___________. I fully understand that I will
not receive advanced notice of the bank deduction associated with my child’s program fees and I authorize
a $35.00 service charge for returned or unpaid drafts from my bank. In the event that Journey Performing
Arts Center has to retain the services of an outside collections agency or initiate a legal suit to enforce
payment of the account, I agree to pay all collections fees, interest, attorney’s fees, court costs and any other
costs associated with collecting all past due amounts.
Signature_____________________________________________Date ____________________
Name (Please Print)_____________________________________________________________
Journey Performing Arts Center
158 Moreland Ave S.E.
Atlanta, Ga. 30315
Tel: 404-622-2585 * Fax: 404-622-2585 * www.JourneyArtsCenter.org
Name on Account:___________________________________________________________
Student’s Name:_____________________________________________________________
Address:___________________________________________________________________
City:___________________________________ Zip: _____________________________
Home Phone:_______________________ Alternate Phone:__________________________
Email:_______________________________________________________________________
Please Circle:
VISA MasterCard Amex Discover
Credit Card/Debit Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: __ __ / __ __
CVI# Located on back:__ __ __
Please read and sign the following agreement:
With my signature below, I authorize Journey Performing Arts Center, Inc. or its assignees to debit the
account referenced above. I understand that my account will automatically be charged on the 25th day of
each month for the amount equal to the remaining balance on my account for the corresponding month. I
authorize these monthly debits between the dates of _______ and ___________. I fully understand that I will
not receive advanced notice of the bank deduction associated with my child’s program fees and I authorize
a $35.00 service charge for returned or unpaid drafts from my bank. In the event that Journey Performing
Arts Center has to retain the services of an outside collections agency or initiate a legal suit to enforce
payment of the account, I agree to pay all collections fees, interest, attorney’s fees, court costs and any other
costs associated with collecting all past due amounts.
Signature_____________________________________________Date ____________________
Name (Please Print)_____________________________________________________________
Journey Performing Arts Center
158 Moreland Ave S.E.
Atlanta, Ga. 30315
Tel: 404-622-2585 * Fax: 404-622-2585 * www.JourneyArtsCenter.org
| REGISTRATION & AUTO DEBIT FORM |