Piper Summer Registration 2023

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Student Name *

Student Pronouns (optional)

Select your child's program preference from the dropdown menu:
*

Student Date of Birth: *

YYYY

Student Grade as of Fall 2023 *

Student School as of Fall 2023 *

Home Address *

Home Phone *

T-shirt Size *

In accordance with New York State Department of Health’s recommendations, we require that all families submit proof of MMR (Measles Mumps Rubella) vaccination. In addition, all participating children will need to show proof of COVID vaccination. *

My child has been vaccinated against MMR (REQUIRED)

My child has been vaccinated against COVID-19 (REQUIRED)

Required

My child has the following activity or medical restrictions. Please elaborate so that we may better meet your child's needs.
*

By participating in Piper Theatre’s Programs, you agree to the terms of the Behavior Policy. Piper is committed to ensuring that all participants who attend are provided an atmosphere in which they can learn together free from harassment or intimidation. Fun and safety are only possible when all participants agree to work collaboratively. You and your child are advised to inform any member of the staff about any conduct that is offensive or is in contradiction to our commitment to a harassment-free environment. All participants are expected to show respect for lead teachers, teaching assistants, fellow students, staff, guests and facilities. Disruptive or dangerous behaviors and physical aggression are not acceptable. Our teaching artists are professionals who use sound, positive management tools within their classes. If any participant does not respond to these measures, the participant will be escorted to the office for a time out. If the problem behavior persists, we will communicate with the parents or guardians and the participant may be removed from the program with no refund of program fees.
*

I have read and agree to Behavior Policy

Required

Parent/Guardian Name *

Parent/Guardian Email *

Parent/Guardian Cell Phone *

Parent/Guardian Add'l Phone (if applicable)

Parent/Guardian 2 Name (if applicable)

Parent/Guardian 2 Email (if applicable)

Parent/Guardian 2 Cell Phone (if applicable)

Emergency Contact Name *

Emergency Contact Best Phone *

Emergency Contact Relationship to Student *

Release and Waiver of Liability: While participating in activities at Piper, each student is assumed to be voluntarily performing activities for which he/she assumes all risk, consequences and potential liability. I hereby release and hold harmless Piper Theatre Productions and the Old Stone House of Brooklyn and its agent or agents from any and all claims arising or resulting directly or indirectly from participation in Piper Theatre activities. I authorize Piper Theatre Productions to take necessary action in case of emergency if I am unable to be reached. In addition, I authorize Piper Theatre Productions and the Old Stone House to use photographs and/or recorded video in which my child appears in promotional literature, ads, displays or any format representing the program.
*

I have read and agree to Release and Waiver of Liability

Required

My child has permission to attend any and all program field trips: *

Yes

Required

My child has permission to leave independently after the program each day: *

Yes

No (if no, please email the name of authorized pick up person(s) to justine@pipertheatre.org)

Required

I will make payment by the following method: *

Electronic transfer (no fee)

Credit Card (3.5% + .99 fee applies)

Check mailed to Piper Theatre Productions PO Box 150613 Brooklyn, NY 11215

Required

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