Registration Form – PERFORMING HEARTS MOBILE

Child's Full Name

First

Last

Parent/Guardian Full Name

Parent/Guardian Email

Parent/Guardian Phone Number

Childcare Center

Child's Age Group

Registration Fees

Preschool Program (1-2years old) – $15.00
PreK Program (3-5 years old) – $16.00
Afterschool Program (5-13 years old) – $17.00

Classes are scheduled on a weekly basis at your child’s childcare center. If classes are cancelled for any reason, they will be rescheduled and made up on another day.

Total

Item Quantity Qty Total

There are no products selected.

Registration Fees – Preschool Program (1-2years old) 1 $15.00

Registration Fees – PreK Program (3-5 years old) 1 $16.00

Registration Fees – Afterschool Program (5-13 years old) 1 $17.00

Total $0.00

Additional Comments

If you have any special requests or comments, please let us know.

Stripe Credit Card

By registering, you consent for Performing Hearts Mobile to charge a recurring weekly fee based on your age group selection. If you have any questions or concerns, please email support at [email protected]

Photographic/Video Release:

Please be advised that your child may be photographed during various Performing Hearts Mobile events and activities. By checking this box, I authorize the use of my child’s name, likeness, photographs, and video recordings in any medium (including print publications, website, social media, etc.) for any legitimate purpose that Performing Hearts Mobile deems appropriate, including promotional and archival uses, without compensation to me or my child.

Group Makeup Number

Parent/Legal Guardian Consent, Waiver, and Release Form for Makeup Application:

By checking this box, I hereby grant my full consent and authorization for my child to have makeup applied by the staff, contractors, or volunteers of Performing Hearts Mobile. Specific Details of Makeup Application: Makeup may include (face paint, foundation, stage makeup, special effects makeup like liquid latex if applicable). Makeup may be applied by various members of the production team (costumers, directors, volunteers, etc.). I understand that while Performing Hearts Mobile will take reasonable care in using hypoallergenic and natural products where possible and ensuring clean application, reactions may still occur. I will inform the production staff immediately of any changes to my child’s health or allergy information. Waiver of Liability and Release: By checking this box, I acknowledge that the application of makeup, while generally safe, involves inherent risks, including but not limited to, allergic reactions or skin irritation. I agree to assume all risks associated with my child’s participation in the makeup application process. In exchange for my child’s participation, I, on behalf of myself and my child, family, heirs, and executors, hereby release, indemnify, and hold harmless Performing Hearts Mobile, its owners, directors, employees, staff, and volunteers from any and all claims, demands, actions, causes of action, suits, costs, expenses, liabilities, and damages whatsoever that may arise from any injury, damage, or loss to my child, my property, or myself resulting from or in connection with the makeup application, except in the case of proven gross negligence by the organization. By checking the box, I verify that I have read this consent, waiver, and release form, fully understand its terms, and I have agreed voluntarily. I am the parent or legal guardian of the minor named herein and have the legal authority to sign this form.