Student Legal Name *

Nickname

Current Grade Level *

Race / Ethnicity *

Last 4 of SSN *

Student DOB *

Street Address

City, State, Zip Code

How Student Attends Creative Genius *

Student ID *

School Name *

Has your student attended a TPA program before?

Yes

Parent/Guardian Name *

How Did You Hear About Us?

Parent/Guardian Email *

Parent/Guardian Phone Number *

Relationship to Youth

Emergency Contact Name

Emergency Contact Phone

Text message opt ins *

By checking this box, I consent to receive non-marketing text messages from The Performers Academy about program enrollment confirmations, scheduling updates, and program-related notifications. Message frequency varies. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, event announcements, and program updates from The Performers Academy at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Primary Discipline/Area of Interest

Secondary Discipline/Area of Interest

I am interested in attending the following days (Must pick at least 2):

List medications the youth is prescribed, including dosage and frequency *

List any dietary restrictions the youth has. Include here if you do not want TPA to provide food to your student without permission. *

List any allergies the youth may have *

How does the youth get along with peers? Are there any social concerns? *

Does your child have a history of any mental health needs? *

Does the youth have a history of running away? *

Would you like to provide any other details about the youth?