Registration Form

Leif’s Improv Acting Playhouse

Registration Form Fall / Winter 2018

HANGAR 5, FLOYD BENNETT FIELD

BROOKLYN, NY 11234

(P): (718)-758-7518

(F): (718)-758-9801

 

Registrant’s Information

____________________________________        Birth Date ____/____/____     Age ________    Sex:    M      F

First                              Last

School Attending: ________________________    Grade _________  (If Applicable)

 

Home Address _______________________________________ Apt#_______ City______________ State________ Zip__________

 

Phone #   ___________________________    Phone #   ___________________________    Email __________________________

PROGRAM DATES/FEES

(Please circle all that apply)

Child Classes (Ages 5-8 & 9-12)

*YOUTH CLASSES BEGIN TUESDAY September 4th, 2018*

Intro to Acting

Tuesday

5:00pm – 6:00pm

Cold Reading/Audition

Tuesday

6:00pm – 7:00pm

On Camera Commercial

Tuesday

7:00pm – 8:00pm

16 Weeks $375 $375 $575

 

**Ask about Adult Improv Therapy Classes**

One Time Trial Class Fee: $35.00

*Please note this trial class can only be used one time total, regardless of different sessions*

  • Classes must be taken consecutively.
  • Each child is allowed one make-up class when they register.

*PLEASE NOTE: A $35 ANNUAL AVIATOR MEMBERSHIP IS REQUIRED FOR EACH STUDENT TO REGISTER*

**ALL PARTICIPANTS MUST FILL OUT PROPER AVIATOR SPORTS & EVENTS CENTER WAIVER** 

 

PERSONAL INFORMATION

Home Address:________________________ Apt #_____ City_________ State______Zip_______

 

Home Phone Number:___________________ Primary E-Mail Address _______________________

 

Parent Information Date of Birth Cell Phone Work Phone E-mail
Mother’s Name
Father’s Name

 

EMERGENCY CONTACTS (Other than Parents)

  1. Full Name: _______________________ Relationship__________ Phone____________
  2. Full Name: _______________________ Relationship__________ Phone____________
  3. Full Name: _______________________ Relationship__________ Phone____________


CREDIT CARD INFORMATION

I ________________________ would like to store my credit card information for automated payments, or for payments made at any time over the phone.

Card holders name ________________________ Card #_______________________ Exp. _______

Signature: _______________________________ Date _____________________

Participant Release of Liability and Assumption Risk Agreement

I hereby acknowledge and recognize that all activities within the Aviator Sports Summer Day Camp involves inherent risks, dangers, and hazards which can cause serious personal injury or death.  I understand that despite Aviator Sports & Events Center’s best efforts, not all inherent risks can be eliminated from the Activity.  As such, I hereby freely assume and voluntarily accept all known and unknown risks of serious injury or death while participating in the activities at Aviator Sports & Events Center.  My child’s participation in the activities is voluntary, and I recognize that they are participating despite knowledge of the inherent risks of the activities.  I acknowledge that the staff of Aviator Sports & Events Center has been available to more fully explain to me the nature of, and inherent risks in the activities.  I further acknowledge and recognize that the best way to reduce the risks of serious injury or death is to use common sense and obey all posted signage.

Parent/Guardian Signature: ___________________________________

Date:                               ___________________________________