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619 Productions Enrollment Form
Student Name
*
First
Last
Date of Birth
*
Age
*
Selected Course (s)
*
Attachments
*
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Gender
*
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Male
Female
Physical Issues
*
Parent/Guardian
*
Address
*
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Email
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Contact Phone Number
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Emergency Contact & Phone Number
*
Race / Nationality
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Referral or Contractual Client
*
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Private Agency
Tarantino County Juvenile Dept.
Government Agency
Household Income Verification (optional )
*
Number in Household
*
Need Assessment
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I am able to pay the full class price
I am not able to pay and would like a full scholarship.
I am not able to pay and would like a partial scholarship.
I am not able to pay due to COVID-19 and would like a full scholarship.
Agreement - To attend the artistic session indicated above and agree to follow the rules at hand. I am responsible for my or my child’s actions, including damages to product(s) and or property of 619 Productions and connected venues. I understand that 619 Productions, Inc. is not responsible for any physical injuries (sprains, pulled muscles, illnesses, broken limbs, etc.) that may occur in and during virtual class or on property. I am also aware that any conduct / behavior problems (excessive defiance, fighting, harm to others, etc.) will be grounds for student dismissal from the program without a refund. We encourage excellence, appropriate behavior and punctuality. Thank you for your cooperation. Now let the creativity begin.
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Home
About
Staff and Directors
Press
Gallery
Classes
Youth Classes
Adult Classes
619 Instructors
Enrollment
Productions
Dance Like David
Timmy's Dance
Brown, Black, & Blue
Get Involved
Donate
Community
Contact
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