Next Stop Broadway Registration Form

June 10-14, 2024
FSCJ Artist Series
Nathan H. Wilson Center for the Arts
11901 Beach Blvd. Jacksonville, FL 32246

PLEASE NOTE: Payment is required to hold your spot and to complete this application. Click Here to make a payment and then return to complete and submit this application.

Child Information

First Name*

Last Name*

Date of birth*

Gender*

Age*

If you have a friend attending Next Stop Broadway who is the same age, list his or her name to be placed in the same group:

Parent/Guardian Information

Please list one parent/guardian in this section as the primary contact for your child. Additional contacts can be added in the next section if desired.

First Name*

Last Name*

Relationship to child*

Email Address*

Phone Number*

Additional Contact Information

Optional, please only fill out if there is another individual in additional to the primary contact listed above.

Name

Phone Number

Authorized Sign Out

In order to ensure the safety of all, we will not release a child to anyone unless authorized to do so in writing.

The following person(s) has permission to pick up my child.* (Don't forget to include yourself in this list if you will be picking up your child.)

Name

Phone Number

Name

Phone Number

*Additional pick up names can be added on a case by case basis the week of Next Stop Broadway.

My child has permission to leave Next Stop Broadway on his/her own.*

If you select "No," you must come inside the Nathan H. Wilson Center for the Arts at the end of each day to sign your child out. Your child will not be able to meet you in the parking lot unless permission is granted to leave on his/her own.

I am aware and agree that once my child leaves at the end of each session day that neither Next Stop Broadway nor FSCJ Artist Series are responsible for his/her whereabouts, actions or welfare.*

I agree

Medical Information

Insurance Verification

By checking the 'yes' box, I certify that I have medical insurance covering my child. Also that the information in this release is correct as far as I know. My child has permission to take part in all Next Stop Broadway activities. I understand that every attempt will be made to contact me in case of an emergency. In the event that I cannot be reached, I give consent to emergency transportation, x-rays, medical treatment(s), surgery or dental care for my child. I agree to assume responsibility for charges so incurred.

Insurance company name

Member ID

Family doctor name

Family doctor phone number

Health Concerns

Please list any physical injuries or chronic health problems that we should be aware of, e.i. asthma, epilepsy, knee injury, etc.

Medical restrictions or allergies

Dietary Consideration

Medications

Please list any medications your child is taking or any other information that we should be aware of.

I give Next Stop Broadway permission to administer any medications that my child needs assistance in taking. I will provide a copy of the physician's prescription and enough medication in its prescription bottle for the entire week of camp.*

Yes
No
Does not apply

Do you give Next Stop Broadway permission to administer Tylenol or Advil to your child in the event that he or she is not feeling well? Check all that apply.*

Tylenol
Advil
Neither

Health/Immunization Information

Please include date of last examination, date of DPT/TB, Polio, MMR immunization and date of last tentanus shot

Photo and Liability release

I give Next Stop Broadway and FSCJ Artist Series permission to take photographs, video and/or audio recordings of my child, and use them in connection with the promotion or publicity of Next Stop Broadway. I hereby release Next Stop Broadway and FSCJ Artist Series and their respective employees, independent contractors, directors and/or officers from any legal or financial claims. *

I agree that neither Next Stop Broadway nor Florida State College at Jacksonville, Foundation Inc. dba FSCJ Artist Series, not any of its employees, independent contractors, directors and/or officers will be held liable for any injury which may occur to my child while attending Next Stop Broadway. This includes, but is not limited to, any activities in which he/she may participate including classes in singing, acting, dancing, physical comedy, stage craft, theatrical mask work, warm-up exercises*

Agree

Payment

For this next section, you will need the account name and order number from the order confirmation sent via email after payment was made. Payment must be made online. If you have not made payment yet, you can do so by clicking HERE. Spots for camp are reserved when payment is received.

Account name*

Please enter the account name in which you have paid tuition under.

Order confirmation*

Please enter the order number provided via email upon paying tuition.

Refund Policy *

If you need to cancel after being accepted into Next Stop Broadway, your payment is refundable minus a $50.00 handling fee up to 30 days prior to the program's start date. For cancellations within a 30 day period, all payments are non-refundable.

I understand the refund policy