Piper Afterschool Registration

Student Information

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PTW Fall 2023: Rumplestilskin
PTW Spring 2024: Little House on the Prairie

PTW: Fun, games, and a one act production at the Old Stone House. Ten Sessions / 3:30pm – 5:30pm / Ages 10 -12 / $375 FALL: Session 1: Rumplestilskin, An original adaptation by Patti Veconi. (10 weeks / 10 sessions) Tuesdays, Sept 12, 19, 26, October 3, 10, 17, 24, 31, Nov 14, 21 SPRING: Little House on the Prairie (10 weeks / 10 sessions) Tuesdays, Jan 9, 16, 23, 30, Feb 6, 13, 27, March 5, 12, 19

Student Name*

First Last

Student Pronouns (optional)

Student Date of Birth*

Student Current Grade*

Student Current School*

Student Home Address*

Street Address City State ZIP Code

Student Home Phone*

Student Cell (if applicable)

In accordance with New York State Department of Health’s recommendations, we require that all families submit proof of MMR (Measles Mumps Rubella) vaccination. Regarding Covid-19, Piper will consider all guidelines from the Centers for Disease Control and Prevention. Proof of Covid-19 vaccination is required to attend Piper programs*

My child has been vaccinated against MMR & Covid-19

Email proof of MMR & Covid-19 vaccinations to info@pipertheatre.org or mail to Piper Theatre Productions, PO Box 150613, Brooklyn, NY 11215. Waivers of Liability as related to Covid-19 will be sent to families electronically for review and signature.

My child has the following activity or medical restrictions. Please elaborate so that we may better meet your child's needs.

Behavior Policy*

I have read and agree to the behavior policy below.

By participating in Piper Theatre’s Programs, you agree to the terms of the Behavior Policy. Piper is committed to ensuring that all participants who attend are provided an atmosphere in which they can learn together free from harassment or intimidation. Fun and safety are only possible when all participants agree to work collaboratively. You and your child are advised to inform any member of the staff about any conduct that is offensive or is in contradiction to our commitment to a harassment-free environment. All participants are expected to show respect for lead teachers, teaching assistants, fellow students, staff, guests and facilities. Disruptive or dangerous behaviors and physical aggression are not acceptable. Our teaching artists are professionals who use sound, positive management tools within their classes. If any participant does not respond to these measures, the participant will be escorted to the office for a time out. If the problem behavior persists, we will communicate with the parents or guardians and the participant may be removed from the program with no refund of program fees.

Parent/Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Enter Email Confirm Email

Parent/Guardian Cell Phone*

Parent/Guardian Additional Phone (if applicable)

Parent/Guardian 2 (if applicable)

First Last

Parent/Guardian 2 Cell (if applicable)

Parent/Guardian 2 Additional Phone (if applicable)

Parent/Guardian 2 Email (if applicable)

Enter Email Confirm Email

Emergency Contact Full Name*

Provide a contact OTHER THAN the parent/guardian(s) already named.

Emergency Contact Phone*

Emergency Contact Relationship to Student*

Provide a contact OTHER THAN the parent/guardian(s) already named.

Please tell us how you learned of this program

Permissions

Release and Waiver of Liability: While participating in activities at Piper, each student is assumed to be voluntarily performing activities for which he/she assumes all risk, consequences and potential liability. I hereby release and hold harmless Piper Theatre Productions and the Old Stone House of Brooklyn and its agent or agents from any and all claims arising or resulting directly or indirectly from participation in Piper Theatre activities. I authorize Piper Theatre Productions to take necessary action in case of emergency if I am unable to be reached. In addition, I authorize Piper Theatre Productions and the Old Stone House to use photographs and/or recorded video in which my child appears in promotional literature, ads, displays or any format representing the program.*

I agree to Waiver

Payment Information

I will pay by the following method:*

Check
Credit Card (3.5% + .99 fee applies)
Electronic transfer (no fee)
Cash

I am interested in applying for financial aid

Yes

An application will be emailed to you with workshop confirmation.

Email

This field is for validation purposes and should be left unchanged.

Registration – Piper Afterschool (2023-2024)

Student Information

Parent/Guardian Information

Permissions

Payment Information