Please make checks payable to: Sugar Loaf Performing Arts Academy
Mail to: P.O. Box 222 Sugar Loaf, NY 10981
STUDENT NAME: ____________________________________ AGE: ______________________________
DATE OF BIRTH: ______________________________ PARENT’S NAMES: __________________________
ADDRESS: ____________________________________________________________________________
CITY: ___________________________________ STATE: _______________________ ZIP: ____________
EMAIL: _______________________________________________________________________________
PARENT’S CELL PHONE: _____________________________EVENING: ____________________________
EMERGENCY CONTACT NAME: ____________________________________________________________
EMERGENCY CONTACT NUMBER: _________________________________________________________
EMERGENCY CONTACT RELATIONSHIP TO CHILD: _____________________________________________
MEDICAL INSURANCE: ____________________________ MEDICAL ID NUMBER: ___________________
PHYSICAL LIMITATIONS OR ALLERGIES? IF SO, PLEASE EXPLAIN: _________________________________
_____________________________________________________________________________________
SIGNATURE: _________________________________________ DATE: ____________________________
PRINT NAME OF PARENT SIGNING FORM: ___________________________________________________
WAIVER OF LIABILITY
Any activity involving height or motion incurs the possibility of accidental injury. While it is our intention to provide
your child with safety and protection, it is not the responsibility of Sugar Loaf Performing Arts Academy or Sugar
Loaf Performing Arts Center, or its staff, to be held liable for any injury occurring while in Sugar Loaf Performing
Arts Academy instruction or supervision. As parent or guardian of above named student, I hereby agree to hold
harmless Sugar Loaf Performing Arts Academy and Sugar Loaf Performing Arts Center and assume full financial
responsibilities for any and all treatment required due to injury while training at Sugar Loaf Performing Arts
Academy.
PARENT’S SIGNATURE: __________________________________________________________________
CONSENT FOR MEDICAL TREATMENT
In the event we are unable to contact the authorized person(s) listed on this form, I, the parent or guardian of the
above-named student, hereby give my consent for emergency medical care as prescribed by a duly licensed doctor
of medicine or dentistry. Transportation to the hospital will be at the discretion of the Emergency Technicians on
site.
PARENT’S SIGNATURE: __________________________________________________________________
I understand I am responsible for timely payment of my child’s classes and realize he/she will lose their reserved
place in class if our account does not remain current.
I understand that Sugar Loaf Performing Arts Academy and Sugar Loaf Performing Arts Center supports a website
and may post student’s photos. Students will only be identified by name on the website and the Sugar Loaf
Performing Arts Academy Facebook page if parents give consent.
PLEASE CIRCLE: May we use your child’s name?
YES
NO
I have read and understand the Sugar Loaf Performing Arts Academy above policies and will follow them as a
member of the Academy.
PARENT’S SIGNATURE: ______________________________________________ DATE: ______________
FOR OFFICE USE ONLY
DATE DEPOSIT RECEIVED: __________________________________
AMOUNT: $______________________
BALANCE DUE: $__________________
PAID IN FULL: Y/N
PAYMENT PLAN: ________________________________________________________________
REGISTRATION FEE: _________________ DATE: _____________________ ON LINE: _________
CHECK #(s) ___________________________________________________
BY MAIL ____________________________________________________
DATE RECEIPT SENT: __________________________________________
METHOD:
____ In Person
____Email
____USPS