Performing Arts Conservatory Registration

Student Name*
First Last
Parent/Guardian*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
School*
Current Grade Level*
Session
- Fall (Oct 2 - Nov 20)
- Spring (Feb 26 - Apr 2)
- Both Fall and Spring

Photo and Video Release*
- I agree to photo and video release
In consideration of my son/daughter's engagement as a photo or video subject by Broadway Theatre League of NEPA, Ballet Theatre of Scranton, and Arts in Education NEPA, I hereby grant the right and permission to copyright, use, reuse, and publish photographs or videotape images made of my son/daughter for the NEPA Performing Arts Conservatory's educational purposes, including use in advertisements for public relations and development purposes. I hereby release NEIU and its authorized representatives, including the photographer or videographer, from any liability by virtue of any blurring, distortion or alteration that may have occurred in the making of such images and from any liability for claims of libel or invasion of privacy for any reason.

Hold Harmless Agreement*
- I have read and understand the Hold Harmless Agreement
As parent/guardian of a participant in the NEPA Performing Arts Conservatory, I understand that Broadway Theatre League of Scranton, Inc. and their partners do not provide any medical insurance coverage for the accidental injuries or illness or coverage for accidental injuries or illness or coverage for personal property damage. I agree to release and hold harmless, Broadway Theatre League of Scranton, Inc., Ballet Theatre of Scranton, Arts in Education NEPA, and the NEPA Performing Arts Conservatory from any and all responsibility for any injuries or damages not directly caused by the negligence of the program its officers, agents, or employees.
Parental Consent*
- I give my permission for my son/daughter to attend the NEPA Performing Arts Conservatory program. I understand that daily attendance is mandatory and that the only excusable absence would be for medical reasons.