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Student's Name:
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Age:
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Sex:
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Residence Address:
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Ethnicity:
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Phone Number:
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Alternate Phone Number:
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Please provide any information that may affect the student's performance we should be aware of (ie. disabilities, medications, etc.)
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Parent or Legal Guardian's Name:
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Relationship to Child:
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Phone Number:
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Alternate Phone:
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E-mail Address:
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Best Contact Method:
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Authorized to pick up child:
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If parent/guardian is not authorized to pick up child, who will be responsible for providing transportation?
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Emergency Contact/Authorized to Pick-up Student Name:
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Phone Number:
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Alternate Phone:
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Who referred you to our program?
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What Organization/School/Professional Affiliation/DCS are they from?
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If you were not referred, how did you hear about the program?
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Enroll me in the following Monday class
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Tattoo Design - 9th-12th
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Enroll me in the following Tuesday class
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DJ Spin 1 - 8th-12th
DJ Spin 2 - 8th-12th (pre-requisite DJ Spin 1)
Art of Music Video - 7th-12th
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Enroll me in the following Wednesday class
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Guitar 1: Beginning - 7th-12th
Guitar 2: The Next Step - 7th-12th (pre-requisite Guitar 1 or prior experience)
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Enroll me in the following Thursday class
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Hip Hop - K-2nd
Hip Hop - 3rd-5th
2 Dimensional Arts - 3rd-6th
3 Dimensional Arts - 3rd-6th
Mural Arts - 9th-12th
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By registering for ASAP, I give permission for Tippecanoe Arts Federation to use photographs, video and/or audio recordings of class participation for the promotion of Tippecanoe Arts Federation, including but not limited to advertisements, video, print, and website. I give permission for my name and identity to be revealed therein or by descriptive text or commentary.
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By registering for ASAP, I commit to the classes. I will attend, arrive on time, and participate in all the classes. I will let the staff of the Tippecanoe Arts Federation know if I am unable to attend or be late to a class. I will provide my own transportation to and from ASAP.
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In consideration of Tippecanoe Arts Federation (TAF) allowing th eminor child named above to participate in ASAP, on behalf of the minor child and his/her next of kin and/or any other legal and personal representatives, and on behalf of myself, I hereby Release and futher agree to Indemnify and Hold Harmless TAF and its officer, directors, instructors, organizations, sponsors, venues and property owners where the programs take place, employees and other agents with respect to
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any liability, claims, demands, causes of action, damages, losses or expense (including court costs and attorneys fees) of any kind or nature that may arise out of, result from, or relate to the minor child's participation in ASAP, including, but not limited to any claims cuased in whole or in part by the negligence of the released parties.
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I further agree that if, despite this agreement, I make or anyone on behalf of the minor child or on my behalf makes a claim for liability against any of the released parties, I will indemnify, defend and hold harmless each of the released parties from any such liability that may incurred as a result of such claim.
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After clicking submit below, click continue at the very top of the page to verify your information, then click continue.
You will receive an e-mail confirmation within 5 business days. If you do not receive an e-mail confirmation within 5 business days, please contact us at 765-423-2787 or taf@tippecanoearts.org
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