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The Child Prodigy Series Class Schedule:
( )
Summer Semester I
06/21/10 – 07/09/10
( ) Summer
Semester II 07/12/10 – 07/30/10
( )
Fall Semester I 08/23/10 - 10/15/10
( )
Fall Semester II
10/18/10 - 12/10/10
( )
Winter Semester 01/03/11 - 02/25/11
( )
Spring Semester 02/28/11 - 04/29/11
E-mail addresses are required for class confirmation. Print form below, complete, then mail
to : Marcy Gilroy A Prelude to the Classics 4224 Escondito Circle Sarasota,
Florida 34238 | Parent(s) | | Caregiver's Name | Full Mailing
Address
Email | | City State Zip | | Phone(s):
Home Work | | Child #1 New ( )
Returning ( )
Child # 2 New( ) Returning ( ) | Date of Birth
Month/Day/Year __________________ | Female ( )
Male ( ) | | Color of
piano (red, black, white, or pink) __________ Delivery
Date of piano requested _____________
| | Is Child in Preschool Program Y ( ) N (
) | Female
( )
Male ( ) | Series: Spring, Winter, Fall 8 week sessions twice per week Summer 3 week sessions
three times per week
(
) Winter Beg Mon/Fri 5:30–6:15 ( )
Winter Advanced Mon/Fri 6:15-7PM ( ) Winter Beg Mon/Wed 4:45-5:30 ( ) Spring Beg Mon/Fri 5:30–6:15
( ) Spring Advanced 6:15-7PM
( ) Spring Beg Mon/Wed 4:45 - 5:30 (
)Fall I Beg Mon/Fri 5:30–6:15 ( ) Fall
I Advanced 6:15-7PM ( ) Fall
I Beg Mon/Wed 4:45 - 5:30 (
)Fall II Beg Mon/Fri 5:30–6:15 ( ) Fall II Advanced 6:15-7PM
( ) Fall II Beg Mon/Wed 4:45 - 5:30 ( )Summer I
Mon/Fri 5:30 – 6:15, Wed 8:30 – 9:45
( ) Summer II Mon/Fri 5:30 – 6:15,
Wed 8:30– 9:45
| Has your child ever played
an instrument, if yes, what type, how long _______________________________________________________ | | Has parent or caregiver ever
played an instrument, how long ____________________________________________________________ | Any allergies
and preference for snacks and drinks
_____________________________________________________________
Print, sign, send with check for $350 per semester, (plus $100 for piano for first time
students) to Marcy Gilroy A Prelude to the Classics The Child Prodigy Series 4224 Escondito Circle Sarasota,
Florida 34238 |
THIS RELEASE MUST BE SIGNED AND SUBMITTED ALONG WITH
THE ABOVE REGISTRATION FORM IN ORDER FOR YOUR CHILD TO RECEIVE CLASS MATERIALS AND BE ABLE TO PARTICIPATE
IN CLASS. RELEASE, INDEMNIFICATION AND MEDICAL TREATMENT AUTHORIZATION I voluntary
agree to my child's participation in activities put on by A Prelude to the Classics The Child Prodigy Series. I acknowledge that these activities
may involve my child's performing physical movements in accompaniment to the singing or music in the class, and that
such physical movements are moderate and are not intended to cause my child to experience any physical strain or overexertion
and I attest that my child is in good health and physically and psychologically able to participate in such physical activities.
For as long as my child is enrolled or participating in any activity put on by A Prelude to the Classics The Child Prodigy
Series, I hereby assume all risk of injury to my child attendant to his/her participation in A Prelude to the Classics The
Child Prodigy Series activities, and I hereby agree to forever release, waive and discharge A Prelude to the Classics The
Child Prodigy Series, its officers, directors, shareholders, employees, teachers agents and successors and assigns from any
and all demands, claims, causes of action and damages in connection with any injury to my child, in connection with his/her
participation in A Prelude to the Classics The Child Prodigy Series which injury is not directly caused by the gross negligence
or intentional act of A Prelude to the Classics The Child Prodigy Series, its officers, directors, shareholders, employees,
teachers or agents. I further agree that neither I nor my assignees will make a legal claim against or attach the property
of A Prelude to the Classics The Child Prodigy Series, its officers, directors, shareholders, employees, teachers, agents
and successors and assigns for injury or damage caused by my child's participation in A Prelude to the Classics The Child
Prodigy Series activities unless caused by the gross negligence or intentional act of A Prelude To the Classics The Child Prodigy Series, its officers, directors, shareholders, employees, teachers
or agents. I further agree to release A Prelude to the Classics The Child Prodigy Series from liability for any of my child's property
that may be lost, stolen or damaged while my child is participating in A Prelude to the Classics The Child Prodigy Series
activities. I also forever release, waive and discharge A Prelude to the Classics The Child Prodigy Series, its officers,
directors, shareholders, employees, teachers, agents and successors and assigns from any and all demands,
claims, causes of action and damages in connection with any injury to me suffered on A Prelude to the Classics The Child Prodigy
Series premises or while entering or leaving such premises which injury is not directly caused by the gross
negligence or intentional act of A Prelude to the Classics The Child Prodigy Series,
its officers, directors, shareholders, employees, teachers or agents. There may be occasions where my spouse or my child's
caregiver will accompany my child to A Prelude to the Classics The Child Prodigy Series classes; in the event that such person
is injured on A Prelude to the Classics The Child Prodigy Series premises or while entering or leaving A Prelude to the Classics
The Child Prodigy Series premises, I agree to indemnify and hold A Prelude to the Classics The Child Prodigy
Series harmless from and against any and all demands, claims, causes of action and damages in connection
with any injury to such person suffered on A Prelude to the Classics The Child Prodigy Series premises or while entering or
leaving such premises which injury is not directly caused by the gross negligence of A Prelude to the Classics
The Child Prodigy Series its officers, directors, shareholders, employees, teachers or agents. I agree that in the event of
a medical or psychological emergency involving my child, A Prelude to the Classics The Child Prodigy Series, its employees,
teachers and agents have the authority and may in their sole discretion contact 911 emergency services as well as the emergency
contact person designated below. I understand that A Prelude to the Classics The Child Prodigy Series is not a medical services
provider and is not expected to provide medical or psychological services, and that A Prelude to the Classics The Child Prodigy
Series will make its best effort to communicate with my designated contact person in an emergency. I acknowledge that all
costs incurred in providing such emergency medical or psychological services to my child initiated by A Prelude
to the Classics The Child Prodigy Series as provided above are my and not A Prelude to the Classics The Child Prodigy
Series responsibility. This Release, Indemnification and Medical Treatment Authorization shall bind my personal representatives,
heirs, executors, administrators, Assigns and all the members of my family for so long as my child is enrolled in A Prelude
to the Classics The Child Prodigy Series or participating in any activity put on by A Prelude to the Classics The Child Prodigy Series.
Date:
________________ Name of Child:________________________________________
Name of Parent or Legal Guardian :______________________________________________ Payment Enclosed: $__________ Check/Cash
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