REGISTER ONLINE: Pay with Cash or Check

Please fill out this registration form. Every student must complete a registration form each session. 

Pay on or before January 6, 2018. Cash or checks made payable to Moving Arts Exchange will be accepted in person or mailed to:

PO Box 2, Housatonic, MA 01236

Student's Name *
Student's Name
Spring 2018 Classes
Please select classes you wish to enroll in:
Personal Information
Primary Address
Primary Address
Phone
Phone
Date of Birth
Date of Birth
Parent/Guardian & Emergency Contacts
Name of Parent/Guardian 1
Name of Parent/Guardian 1
Parent/Guardian 1 Daytime Phone
Parent/Guardian 1 Daytime Phone
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Home Phone
Parent/Guardian 1 Home Phone
Name of Parent Guardian 2
Name of Parent Guardian 2
Parent Guardian 2 Daytime Phone
Parent Guardian 2 Daytime Phone
Parent Guardian 2 Cell Phone
Parent Guardian 2 Cell Phone
Parent Guardian 2 Home Phone
Parent Guardian 2 Home Phone
Emergency Contact 1
Emergency Contact 1
Emergency Contact 1 Daytime Phone
Emergency Contact 1 Daytime Phone
Emergency Contact 1 Cell Phone
Emergency Contact 1 Cell Phone
Emergency Contact 2
Emergency Contact 2
Emergency Contact 2 Daytime Phone
Emergency Contact 2 Daytime Phone
Emergency Contact 2 Cell Phone
Emergency Contact 2 Cell Phone
Medical Consent Form
Please list ALL medical conditions – physical, emotional, and mental - that we should be aware of - any limitations present that would require additional considerations to enable the student to participate
Please list ALL medications taken routinely by student
Please list any food allergies/medication allergies/other allergies
I, the parent/guardian of the registrant, a minor, recognize the possibility of physical injury associated with training, and hereby release, discharge and/or otherwise indemnify Moving Arts Exchange (MAX) and the teachers/staff/leaders at MAX against any claim by or on behalf of the registrant as a result of the registrant’s participation in classes at MAX located at LifeWorks Studios 50 Castle Street, Great Barrington, MA, and additional sites.
Insurance Information (for students under 18)
Is participant covered by medical insurance?
Subscriber’s Date of Birth
Subscriber’s Date of Birth
The person herein named has permission to engage in all dance classes and rehearsals unless otherwise noted. I hereby give permission to the Moving Arts Exchange (MAX) to provide, seek, and consent to routine health care, administration of prescribed medications, and emergency treatment for me/my child, as may be necessary, including, but not limited to x-rays, routine tests and treatments, and/or hospitalization. I also give permission for MAX to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. It is my intention that MAX be treated as acting in loco parentis if the person herein named is a minor. Further, it is my intention that the appropriate representatives of MAX be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR & 164.510(b)) to the disclosure to the MAX representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant information to the MAX representatives related to the person’s ability to participate in music, theatre, and dance classes, rehearsals, and performances; and (ii) in the case of minors, to provide relevant information to the MAX representatives to keep me informed of my child’s health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by MAX to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips off-site.
Participant Photography/Film Waiver
I grant permission for Moving Arts Exchange to use any photographs/film of my child in brochures, or other media for promotional purposes. I have read and understand all materials in this waiver and agree to abide by these terms. I am aware this is a waiver and release of liability and I sign it voluntarily.
Complete Registration
Thank you for registering for classes. If you have more than one student, please be sure to fill out a form for each one. You will receive an invoice shortly confirming your registration. Please contact max@movingartsx.org if you have any questions.