Student Name
*
First Name
Last Name
Student grade at BPMS
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
Parent/Guardian Phone
*
(###)
###
####
Student Birth Date
*
Parent/Guardian Relationship to the Student
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does your child have any allergies, medical concerns or other things we should know about?
*
Parent/Guardian Place of Employment
*
Household Income Level
*
$29,999 or less
$39,999 to $30,000
$49,999 to $40,000
$59,999 to $50,000
$69,999 to $60,000
$79,999 to $70,000
$89,999 to $80,000
$99,999 to $90,000
$125,000 to $100,000
More than $125,001
Ethnicity
*
Hispanic
Non-Hispanic
Prefer not to answer
Please read and acknowledge the following policies:
Student Behavior Policy – CAC reserves the right to cancel or refuse the registration of a student in a class or workshop if participation by the student is deemed disruptive or interferes with the learning atmosphere and enjoyment of the class/workshop.
Photograph Release – I (the undersigned) hereby grant CAC the right to photograph me or my child during classes and performances, and to use my or their image, photograph, silhouette and other reproductions of their physical likeness in connection with ongoing CAC publicity. I agree that I will not assert or maintain against CAC their successors, assigns and licensees, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any reason in connection with CAC’s authorized use of my child’s physical likeness for CAC publicity purposes. By my signature here I understand that I agree to the above mentioned guidelines and completely turn over all rights to the still photographs to the CAC.
Release, Waiver of Liability, and Indemnity Agreement – I (the undersigned) hereby agree with the Chesapeake Arts Center, Inc. (CAC) to the following by affixing my signature below on this date. In connection with my participation in the CAC program, I understand and acknowledge the nature and extent of the activities that will be involved in the Program and assume the risk inherent in such activities on behalf of myself and any minor children. I voluntarily waive any and all claims, costs, liabilities, expenses (including attorney’s fees), and judgments against CAC, its directors, officers, employees, servants, subcontractors, and agents and hereby release, excuse and discharge CAC, its directors, officers, employees, servants, subcontractors, and agents from all claims, costs, liabilities, expenses (including attorney’s fee), and judgments which may arise out of my participation in the Program and all aspects attendant thereto. The undersigned further agrees to indemnify and hold CAC, its directors, officers, employees, servants, subcontractors, and agents harmless from any and all claims, damages, actions, liabilities, expenses (including attorney’s fees) and judgments that may arise out of my participation with the Program.
Covid-19/Illness Policy - Please do NOT come to class if you, or anyone in your household, are experiencing any covid symptoms (includes any of the following: chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. Please visit chesapeakearts.org/cares for our complete Covid-19 safety policy.
Closings/Cancellations - CAC follows the AACPS school system. If AACPS is closed for a holiday, or weather, the CAC after school program is cancelled for that day and evening. If classes are closed due to weather, instructors are required to verify closure with CAC and then notify students via the email provided on this application.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THESE POLICIES:
First Name
Last Name
