Mosaic Youth Theatre of Detroit Online Registration

Registration

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Welcome to Mosaic Youth Theatre of Detroit! We are thrilled to work with you and your young artists! Please fill out the registration form below.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info
(Not Contact #1 or #2)*

Health Insurance Carrier*

Family Size*

Annual Household Income*

Receive Food/Cash Benefits? *

Scholarship Consideration? Y/N*

Contact #1

Parent/Guardian 1 First Name*

Last Name *

Relationship to Student*

How Can We Contact You?

Home Phone *

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Relationship to Student

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email*

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications

Student Race*

Student Gender*

Student T-Shirt Size *

Please click on the Search button below, then choose the progrma.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email*

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications

Student Race*

Student Gender*

Student T-Shirt Size *

Please click on the Search button below, then choose the progrma.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email*

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications

Student Race*

Student Gender*

Student T-Shirt Size *

Please click on the Search button below, then choose the progrma.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email*

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications

Student Race*

Student Gender*

Student T-Shirt Size *

Please click on the Search button below, then choose the progrma.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email*

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications

Student Race*

Student Gender*

Student T-Shirt Size *

Please click on the Search button below, then choose the progrma.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Media Release

I give my permission for the photographing, audio recording, videotaping, and/or the publication of an existing photograph, audio recording or video of the above named child by Mosaic Youth Theatre of Detroit in its educational, promotional or fundraising materials. I understand that there will be no remuneration or other consideration for the above name child’s participation. I understand that the reproduction of the aforementioned, either in whole or in part, or alone or in conjunction with other photographs, sketches, art work, videotapes, audio recording and text matter, is to be used by Mosaic Youth Theatre of Detroit, its employees, agents, licensees and assignees now and at any time in the future for educational, informational, fundraising, and publicity purposes, and for radio and television broadcasting and distribution, advertising, trade promotion, or art purposes in publications and other advertising and promotional media, anywhere in the world, and I hereby consent to such use on behalf of the above named child. I hereby release Mosaic Youth Theatre of Detroit and its employees, agents, licensees and assignees from any and all claims arising out of such photographing, videotaping, recording, reproducing, broadcasting, publishing, or exhibiting or other use as is authorized by Mosaic Youth Theatre of Detroit or its affiliates.

I've read the above and agree.

Mosaic Code of Conduct Form

Mosaic Youth Theatre of Detroit Code of Conduct Acknowledgement Form
I (Parent and Young Artist) have received the Mosaic Code of Conduct and will conduct myself in the following manner at all times while at Mosaic:
• Be Accountable:
o Take responsibility for your words and actions o Complete tasks on time
• Be Present:
o Attend all rehearsals and performances o Be fully engaged in the artistic process
• Be Prepared:
o Bring all materials to rehearsals o Know lines/music, blocking, cues, and choreography
• Be Supportive:
o Accept others for who they are o Encourage others to explore their uniqueness
• Be Precise:
o Strive for technical mastery
• Be Committed:
o Give 100% energy o Only the best, Nothing less
Young artists are ambassadors for Mosaic and the young people of Detroit. They are expected to behave with self-control and professionalism whenever they represent Mosaic in public. This includes rehearsals where guests are present, at special events, while in off-stage areas during performances, while in the audience of any performance, and during trips. Positive behavior will reflect positively on the young artist, Mosaic and metro Detroit.
The Three Strike Process will be initiated in the event that a young artist has difficulty following the code of conduct.

I've read the above and agree.

Refund Policy

All refund requests must be submitted in writing.

Deposits are non-refundable.

Please note that refunds will take 10-12 business days to get back to you.

As such, please note that checks returned for any reason will incur a $50 fee. If a check is returned, the deposit/installment, plus the aforementioned $50 fee must be paid in full via certified funds within three (3) business days.

I've read the above and agree.

Medical Emergencies

I understand that health/accident insurance coverage is the responsibility of the parent/guardian. I hereby give permission to Mosaic Youth Theatre of Detroit staff and representatives to secure medical, routine medical, surgical treatment, and non-surgical care for the Young Artist names on this form. I authorize Mosaic Youth Theatre of Detroit staff and representatives to transport the Young Artist to the nearest hospital in case of injury, suspected injury, emergency, or suspected emergency in a private vehicle, rented vehicle, or ambulance, whichever is deemed necessary while the participant is in attendance of rehearsals or performances with Mosaic, if the parent/guardian cannot be reached.

I absolve Mosaic Youth Theatre of Detroit and all of its representatives of any and all liability, financial and/or otherwise arising from the administration of any medical care to my Young Artist under the terms of this release. Mosaic Youth Theatre of Detroit is not responsible for payment of any medical expenses incurred during participation in Mosaic Youth Theatre of Detroit’s training programs.

I've read the above and agree.

Sliding Scale/Scholarship Policy

Mosaic strives to make its programs available to all who will benefit from them. Scholarship/sliding scale tuition is based on the income and need of the young artist's family.

For First Stage Summer Camp - Eligibility is based on registration form and funds are allotted on a first come, first served basis.
For Main Stage & Second Stage - Eligibility is based on complete application, including proof of income. Funds are allotted on a first come, first served basis. Incomplete applications will not be considered.

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

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