C4A Registration Form
This form is to register for activities at the Community Center for the Arts (C4A).  Once you have registered you may enroll in lessons, ensembles, classes, workshops, or other C4A offerings.

Each student or participant needs a separate form, even if they are in the same household.

To learn more about our programs, visit c-4a.org 

To connect with a C4A music instructor, sign up for classes and ensembles, or get more information about our programming, send an email to info@c-4a.org 

Sign in to Google to save your progress. Learn more
Email *
Student Information
Student First Name *
Student Last Name *
Student Is *
Birth Date
Required if Student is under 18
MM
/
DD
/
YYYY
Please select one:  *
Parent/Guardian/Adult Student Information
(Adults: please fill in your own information)
First Name *
Last Name *
Email *
Phone *
Optional: Additional parent or guardian
First Name
Last Name
Email
Phone Number
Mailing address
Street Address (include apartment number as needed) *
City *
State *
Zip *
Emergency Contact Information
Who should we contact in the event of an emergency with an adult student, or if the parent or guardian of a minor cannot be reached?
First Name *
Last Name *
Relationship *
Phone Number *
Alternate Phone Number
Does student have any medical conditions, concerns, or modifications we should be aware of?  This information will be shared only with relevant C4A staff.


Medical Concerns? *
Medical details
Finalizing Your Registration
Please read and understand the Consent and Acknowledgement and Medical Release and Authorization below and then sign in the Confirmation Area below before submitting this form.
Contact me About
Would you like to receive our newsletters? Please check all that apply.
How did you hear about C4A?
Questions? Comments? Suggestions?
Informed Consent and Acknowledgement
I hereby give my approval for my child’s (or my) participation in any and all activities prepared by the Community Center for the Arts during the selected activities(s). I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Community Center for the Arts, and all its respective officers, agents, and representatives from any and all liability for injuries to said student arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said student, I hereby waive all claims against the Community Center for the Arts including all instructors, staff, and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Photographs and videos taken during our activities may be used for our promotional purposes without your further consent.  We will not publish or release images that are inappropriate or identify students by name or otherwise reveal their identities.  

Students' names may be listed in programs, on CDs or DVDs, or other media.  They will not be listed in a way that identifies individuals.  Said media will be available to the student and his/her family.

I agree to follow safety protocols,  as listed on the C4A website and in-house signage,  in response to COVID-19 or any other health concern.

Students, their families, and their guests are all responsible for their own safety during participation in our events, whether on or off our premises.  

Students, their families, and their guests are all responsible for their own belongings and equipment during participation in our events, whether on or off our premises.
Medical Release and Authorization
As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child* in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Community Center for the Arts and its affiliates including Directors, teachers, staff, and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

*If an adult student, the same release and authorizations apply, with contact attempt being made with designee listed under emergency contacts.
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Adult student or Parent/guardian of minor may sign by typing name here: *
A copy of your responses will be emailed to the address you provided.
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