registration form summer 2012
Member orders accepted starting Jan. 16. All other orders accepted starting Jan. 23.
You can become a member at any time online, by phone, in person, or on this form.
Please fill out both sides completely
Want to guarantee your spot? Become a member today!
Mail or hand-deliver to: FlynnArts Coordinator Flynn Center for the Performing Arts 153 Main Street, Burlington, VT 05401 or fax both sides of form with credit card info to 802-863-8788 or register online at www.flynncenter.org
Parent/Guardian (if under 18) _____________________________ Relationship to Student _____________ Student’s Name __________________________________________________ ❏ Male ❏ Female Date of Birth (if under 18) ____ /____ /____ Grade as of Sept. 2012 ____ School ______________________
❏I am a new FlynnArts student ❏I am a returning student I am a member of: ❏ Flynn Center ❏ BCA ❏ LCMM ❏ Shelburne Farms ❏ ECHO ❏ VPR Street _____________________________________________________________________________ City_______________________________________________________ Zip ____________________ Daytime/Work Phone _____________________________ Evening Phone _________________________ Cell Phone ________________________ Student’s Cell (if applicable) ___________________________ Email (required) ___________________________ Student’s Email _______________________________ YES! I’d also like to receive: ❏ FlynnArts (class and camp) emails ❏ Flynn Center (performance) emails Parent/Guardian 2 _________________________________ Relationship to Student _________________ Do both parents live in same household? ____________________________________________________
❏ I give the Flynn permission to reproduce photos or video images in which I or my child appear. ❏ I give the Flynn permission for my child to go on short, chaperoned trips in and around the Flynn (if under 18). ❏ I give the Flynn permission for emergency contacts to pick up my son/daughter (if under 18). ❏ My son/daughter may travel home independently (if under 18).
How did you hear about FlynnArts classes? __________________________________________________ Summertime Jazz students: What is your preferred instrument?___________________Years played?_______ List other instruments you play__________________________________________Years played?_______
Please list an emergency contact IN ADDITION TO PARENTS LISTED ABOVE (Adult students, too!): Name ____________________________________________________________________________ Relationship_________________________________ Phone __________________________________
NOTE: If you (or your child) have any allergies or other health concerns, please attach a separate sheet with any information the instructor should know.
“I understand fully that even after responsible precautions have been taken, class activities may involve hazards for which the Flynn Center cannot be held responsible. In the event that I (or my child) become ill or injured during class, I authorize staff to seek emergency care. In signing below, I certify that I (or my child) am covered by health and accident insurance or Medicaid and that in the unlikely case of an accident, I will provide the Flynn Center with the name of the carrier and the policy number.”
Signature (Parent/Guardian if under 18) Date 21 After-camp care is available until 5 pm for camps held on-site at the Flynn.
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