Student Information Form: Spring Semester 2020 Welcome to the 2020 Spring Semester of Performing Arts at Elefante! Please complete the form below, then click “Submit” to send us this important information regarding your student. Required fields are marked with a red asterisk. We look forward to the start of the semester. Thank you for choosing Elefante! Student Name* First Last Parent/Guardian Name* First Last Student Date of Birth Month Day Year Age*Select Student's Age3456789101112131415161718Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneCell Phone*Will be used as primary phone number.Email* Emergency Contact Name* First Last Emergency Contact Phone Number*Class(es)*In which class(es) has the student enrolled? Please check all that apply. 3in1 Monday (ages 7-9) 3in1 Monday (ages 10+) 3in1 Friday Beginning/Int Tap Int/Advanced Tap Broadway Beginners 1 (ages 3-5) Broadway Beginners 2 (ages 6 & 7) Magic with Simon 1 (grades K-3) Magic with Simon 2 (grades 4-7) Musical Extravaganza 1 (Thursday, ages 6 & 7) Musical Extravaganza 2 (Wednesday, ages 8-10) Acting Comedy Previous instrumental music, voice, acting, or dance experience. If any, please indicate and for how long:Does your child have an allergy that requires the use of an Epi Pen?* Yes No My child is allergic to:* Check all that apply from the 3 choices below* An Epinephrine injector has been prescribed for my child. A device designed for self-administered asthma treatment (not necessarily Epinephrine) has been prescribed for my child. My child has received adequate training on how and when to use an Epinephrine injector and can use it properly in case of an emergency. He or she will carry Epinephrine injectors at all times. Authorization to allow self-administration. Select one of the options (required).* I hereby authorize… I hereby DO NOT authorize… …my son/daughter to self-administer the epinephrine auto-injector (Epi-Pen® or similar devices designed for self-administered asthma treatment). I agree to indemnify and hold harmless Elefante Music and School of Performing Arts and any of its staff, volunteers, or agents from lawsuit, claim, loss or expense, demand, or action against them, including reasonable attorneys’ fees, suffered by any of the foregoing indemnities and arising out of a claim related directly or indirectly to my son/daughter’s self-administration of or failure to self-administer the above referenced epinephrine auto-injector. Authorization to allow staff to administer auto-injector. Select one of the options (required).* I hereby authorize… I hereby DO NOT authorize… …Elefante Music and School of Performing Arts staff and volunteers to administer an Epinephrine injector (Epi-Pen® or similar devices designed for self-administered asthma treatment) to my child if he or she appears to have had significant exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless Elefante Music and School of Performing Arts and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them, including reasonable attorneys’ fees, suffered by any of the foregoing indemnities and arising out of a claim related directly or indirectly to administering or failing to administer the Epinephrine injector. I am aware that the injection will likely be administered by a staff member or volunteer who is not a healthcare professional. Any medical or emotional issues you would like us to be aware of:Consent to Treat in the Event of a Medical Emergency*If you cannot be reached in an emergency, do you give permission to the proper medical staff to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child, understand the information on this form will be shared on a “need to know” basis with Elefante Music staff? I agree. Registration Fee*A one-time $25 registration fee applies to new students and will be charged upon review of your records at Elefante Music. Families who have previously paid this registration fee for another class or private lessons, including for a different student, are exempt. If applicable to your account, payment will be processed separately and in addition to the class fee. I have read and understand the terms of the $25 registration fee. May we use photographic images and sound bytes of your child for promotional material? Yes No How did you hear about us?