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 *

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

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?

Prior Student

Yes

🎨 Registration Received!

Thank you for registering your student for Creative Genius at The Performers Academy! Our team will personally review your registration and be in touch within 2–3 business days to confirm enrollment and next steps.

📋 Next step — Code of Conduct: please go to your email inbox. We've sent you a Code of Conduct document to review and sign before your student's first day.

Have questions in the meantime?

We're here to help!

📞 (904) 322-7672

📋 Contact Us → https://jaxtpa.org/contact-us/

Registering another student?

👉 register.jaxtpa.org/creative-genius