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Clement Kids Music Fall 2021 Registration

Clement Kids

Clement Kids Music:
Fall 2021 Registration

August 16 - October 22

Clement Arts: Westminster Campus
2303 Double Churches Road
Columbus, GA 31909

Registration fee must be paid upon completion of this form to secure registration. Please send questions regarding billing to amelia@clement-arts.org.

Your participation helps Clement Arts support foster and adoptive families in our community. Thank you!


Parent/Guardian Information

First Name
Last Name
Country
Address Line 1
City
State
Postal Code

Student Information

Please supply information for each student you'd like to register. You can register up to three students for music classes on this form. Please fill out an additional registration form if you are registering more than three students.

First Name
Last Name
/
/
Child is registering for the following classes (check all that apply):

Does your child have prior music experience? Describe briefly. 

Child in Foster Care?

Does your child have any known allergies or dietary restrictions?

Does your child have any known learning or behavioral diagnosis? This information is kept confidential and only used to help us better serve and instruct your child.

Would you like to purchase a Clement Arts t-shirt for you or your child? Shirts are 1 for $15 or 2 for $25.
If yes, what size?

Student Information #2

First Name
Last Name
/
/
Child is registering for the following classes (check all that apply):

Does your child have prior music experience? Describe briefly. 

Child in Foster Care?

Does your child have any known allergies or dietary restrictions?

Does your child have any known learning or behavioral diagnosis? This information is kept confidential and only used to help us better serve and instruct your child.

Would you like to purchase a Clement Arts t-shirt for you or your child? Shirts are 1 for $15 or 2 for $25.
If yes, what size?

Student Information #3

First Name
Last Name
/
/
Child is registering for the following classes (check all that apply):

Does your child have prior music experience? Describe briefly. 

Child in Foster Care?

Does your child have any known allergies or dietary restrictions?

Does your child have any known learning or behavioral diagnosis? This information is kept confidential and only used to help us better serve and instruct your child.

Would you like to purchase a Clement Arts t-shirt for you or your child? Shirts are 1 for $15 or 2 for $25.
If yes, what size?

Terms & Conditions

I confirm that I am the legal guardian of the child(ren) being registered on this form, and I have chosen to have my child(ren) participate in fine arts instruction given by Clement Kids. I acknowledge that I understand the nature of the activities my child(ren) will be participating in and the possibility that despite precautions, accidents and/or physical injury may occur.

I/we agree to release and hold harmless Clement Kids, including its instructors and staff members from any cause of action, claims, or demands now and in the future. I/we will not hold any of the above liable for any personal injury or any personal property damage or loss which may occur on the premises before, during, or after classes or which may occur at any Clement Kids sponsored event outside the studio.

Furthermore, I/we agree to take full responsibility for my/our behavior in addition to any damage I/we may cause to the facilities utilized by Clement Kids.

I/we authorize and agree that Clement Kids may take and use photographs, videos, or likenesses of myself or my child(ren) as needed for its record keeping, advertising, social media, and/or public relations projects, and that I have no rights to the same and will not be compensated for the same. Clement Kids understands the sensitivities surrounding the photography of children in foster care and will not capture and use any identifiable photographs, videos, or likenesses of children in foster care for any purpose or reason.

Clement Kids will record and analyze program-related data for the purposes of seeking grants to support the ministry of Clement Kids and to improve the positive impact of our classes. Surveys measuring self-esteem will be distributed to all students at the beginning and end of each semester. Instructors will complete assessments at the beginning and end of each semester measuring attainable skill-based goals specific to their classes. Survey data will be used collectively and not based on individual students; only first and last initials will be used to track data. No collected data will be made available to any parent, guardian, or student.

I/we agree for my child(ren) to participate in the above data collection for the purpose of improving the Clement Kids program’s services to children and families.

 

Waiver Consent

Connections

How did you hear about Clement Kids Classes? Check all that apply.
Would you like to stay informed of Clement Arts news and events through our monthly email newsletter?

Billing Information

(An invoice will be sent to you soon. Please allow time for the invoice to be sent.)

Billing Options
Do you have more than one child taking classes with Clement Kids, or is your child taking multiple classes?
Multi-class discount applies to additional child(ren) or if your child is taking more than one Clement Kids class.
Is your family active duty military? (10% discount)

Were you referred by a friend or family to Clement Kids classes? If yes, please include their first and last name below. If no, please type "none".

Payment Info

Registration fee must be paid upon completion of this form to secure registration.

Credit Card Information
Visa MasterCard American Express Discover

Visa®, MasterCard® & Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.

Your total payment will be
Your credit balance will cover
Your credit card will be charged
Your bank account will be charged
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