Register for Afterschool

Your Email*

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Student Information

Select Workshop*

Spring: The Diary of Anne Frank (12-14)

Student Name*

First Last

Please enter your child's name.

Date of Birth*

Current Grade*

Current School*

Home Address*

Street Address City State ZIP Code

Student Home Phone*

Student Cell (if applicable)

My child has the following activity or medical restrictions:

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Parent/Guardian Information

Parent/Guardian Name*

First Last

Cell Phone*

Additional Phone

Parent/Guardian 2 (if applicable)

First Last

Parent/Guardian 2 Cell

Parent/Guardian 2 Additional Phone

Parent/Guardian 2 Email

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Emergency Contact - Full Name*

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

Emergency Contact Phone*

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.

Name

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