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Ages 3 & Up~ $20.00 Academy Members / $25.00 Non-Academy Members ~ PLEASE FILL OUT ONE FORM PER GUEST. ~ Please Note: If you enter a different credit card than that which is on file, the system will automatically change your card on file to the one you are providing. Please go to your portal and make sure the card on file is the one you wish to use.
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Family Information
First Name:
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Last Name:
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Parent
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Students entered below will be added to your family's account
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Birth Date:
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Student Email:
School:
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Grade Level:
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preschool
kindergarten
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Add New Student #2:
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Student's First Name:
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Last Name:
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Student Gender:
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Female
Male
Birth Date:
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(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities-please explain:
Allergies:
Medications-please explain:
Add New Student #3:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities-please explain:
Allergies:
Medications-please explain:
Add New Student #4:
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Student's First Name:
*
Last Name:
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Student Gender:
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Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities-please explain:
Allergies:
Medications-please explain:
Add New Student #5:
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Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
*
Grade Level:
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities-please explain:
Allergies:
Medications-please explain:
Questions/Options:
Total number of tickets needed:
Total Number of Academy Member Guests Attending: (please include the name and ages of each guest) *Parents & immediate family of students enrolled at MJPAA are considered Members.
Total Number of Non-Academy Member Guests Attending: (please include the name and ages of each guest) *Parents & immediate family of students enrolled at MJPAA are considered Members.
Additional Information:
Participant Waiver
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I represent that I am the participant, parent or legal guardian of the participant(s) named above, or I have obtained permission from the parent/legal guardian of the participant(s) named above to execute this agreement on their behalf. I agree that the participant(s) named above and I shall comply with all stated and customary terms, posted safety signs, rules and verbal instructions as conditions for participation in any part and/or program at MJPAA. In addition, if I observe any hazard during our participation, I will bring it to the attention of the nearest MJPAA employee or official immediately.
I've read the above and agree.
Assumption of Risk
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In case of emergency or sudden illness, I hereby give permission for a staff member of Mary Jo's Performing Arts Academy to authorize any physician, nurse practitioner, medical personnel or hospital to render immediate emergency aid as it might be required for the undersigned student's health and safety.
I hereby declare any physical/mental problems, restrictions, or conditions and/or declare the participant to be in good physical and mental health.
It is required that all students be covered by their own family insurance and if injury occurs, it is understood that the students own policy is the only source of reimbursement.
I've read the above and agree.
Photo and Video Release
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I understand and acknowledge that, from time to time throughout the year; myself and my child may be photographed and/or videotaped while participating in functions involving MJPAA. I do hereby authorize Mary Jo's Performing Arts Academy to use these photographs and videotapes for the purposes of illustration, advertisement and publication in any manner whatsoever.
I've read the above and agree.
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Exp Year:
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MS
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