Student Information:

Name (Last, First, Middle Initial):   Date of Birth (00/00/0000):

Home Phone Number:      E-Mail Address:

Mailing Address (Street Name, Number/PO Box):

                         Town/City, State, and Zip Code:

Adult Student - Daytime Phone:   Daytime E-Mail: 

The following must be completed if student is under 18 years of age:

Mother's/Guardian's Name:    Daytime Telephone: 

Daytime E-Mail Address:                 Cell Phone: 

Father's/Guardian's Name:   Daytime Telephone: 

Daytime E-Mail Address:                 Cell Phone: 

Emergency Contact Information:  In case of an emergency, Leddy Center School should contact

Name:     Telephone Number: 

Alternate Transportation Provider (complete if parents will not be transporting student):

Name:     Telephone Number: 

Name:     Telephone Number: 

Summer Class/Camp Information:

  Please indicate which class, camp, and/or lesson  you are registering for.  If registering for a private lesson, be certain to contact the office

for an appointment time (603-679-2781), then circle all dates you are planning to attend; you will be responsible for payment of those lessons.

• PRIVATE VOICE for ages 9 and up; PRIVATE PIANO for ages 6 and up: 30-minute private lessons

Wednesdays: 06/04, 06/11, 06/18, 06/25, 07/02, 07/09, 07/16, 07/23, 07/30, 08/06, 08/13, 08/20, 08/27

Thursdays: 06/05, 06/12, 06/19, 06/26, 07/03, 07/10, 07/17, 07/24, 07/31, 08/07, 08/14, 08/21, 08/28

• PRIVATE GUITAR OR BASS for ages 6 and up: 30-minute private lessons

Thursdays: 06/05, 06/12, 06/19, 06/26, 07/17, 07/24, 07/31, 08/07, 08/14, 08/21, 08/28

• SING OUT! 1 for ages 7 to 11: 06/23 to 06/27, Monday through Friday, 10:00am to Noon

• SING OUT! 2 for ages 12 to 16: 06/23 to 06/27, Monday through Friday, 1:00pm to 3:00pm

• MUSICAL THEATER CAMP for ages 9 to 16: 06/30 to 07/11 (07/12 recital), Monday through Friday, 9:00am to 1:00pm

MINI MUSICAL THEATER CAMP for ages 6 to 7: 07/28 to 08/01, Monday through Friday, 10:30am to Noon

MINI MUSICAL THEATER CAMP for ages 7 to 8: 07/28 to 08/01, Monday through Friday, 12:30pm to 2:30pm

Camp/Lesson Name:         Days and Time: 

Camp/Lesson Name:          Days and Time: 

Camp/Lesson Name:         Days and Time: 

Registration Fee and Tuition: 

  Please remember that you must pay the registration fee ($10.00) and the full tuition at the time of registration.

• Cost for SING OUT! 1 or SING OUT! 2 is $125.00 + $10.00 summer registration fee.

• Cost for MUSICAL THEATER SUMMER CAMP is $275 + $10.00 summer registration fee.

• Cost for MINI-MUSICAL THEATER CAMP 1 is $100.00 + $10.00 summer registration fee.

• Cost for MINI-MUSICAL THEATER CAMP 2 is $125.00 + $10.00 summer registration fee.

• All tuition is payable in advance. 

Tuition Payment: $ + Summer Registration Fee: $10.00  = Total Payment: $

Check # or Money Order #:

Medical Information:

Do you/does the student have any medical conditions which could affect your/his/her participation in class?  (Yes or No)

If YES, what is the condition, and what are its symptoms?

Do you/does the student take any medicines which could affect your/his/her participation in class?  (Yes or No)

If YES, what is the medicine name, and what are its side effects? 

Medical Insurance Information:

Insurance Carrier:   Group/Policy Number: 

Release/Waiver and Payment Agreement:

     I acknowledge that I have enrolled myself/my child in a course at Leddy Center for the Performing Arts, Inc., and that I fully understand and appreciate that any activity which includes motion may cause accidental injury.  I have consulted my physician and received assurances from my physician that the physical activity required of the program for which I have enrolled does not pose a risk to me/my child.  I do not/my child does not have any medical condition/s which would be adversely affected by my/his/her participation in this program.  I understand that I have/my child has the right to participate only to the extent I/he/she am/is comfortable, and I/he/she will limit my/his/her conduct accordingly. 

     I accept responsibility for any injury, physical or emotional, which might arise out of this activity and agree to hold

Leddy Center for the Performing Arts, Inc., harmless for any damages and/or costs, and will reimburse any legal fees, which may be incurred should I make demand or institute suit and be unsuccessful in any such action.  If I am unreachable, or I am/my child is unable to speak in the event of an injury, I grant permission for medical treatment to be given.

     I understand and acknowledge that I am responsible for paying for all lessons whether I/my child attend/s the lesson or not.  Furthermore, I fully understand when tuition payments are due, and will make payment on time or will be assessed a $10.00 late fee per week that payment is late.  I also understand that should I fail to make payment within one week of the due date, I/my child will not be allowed into class until payment has been made in full, including late fee.  Should this happen more than once, I understand that Leddy Center retains the right to re-assess the situation and take additional steps to protect its teachers, who rely on tuition payments for their income.  There are NO REFUNDS - NO EXCHANGES.

Please print this form, then sign and date below.  Registrations are not accepted without signature and date.

Adult Student's or Parent/Guardian's Signature: ___________________________________________   Date: