Purple Deer Music Academy - Friday Fun Night

What is Friday Night Fun?

Friday Night Fun on May 19th at Purple Deer Music Academy of Fairfield! While you go out, your child (age 4 and up) will enjoy a pizza dinner (please let us know allergies), a chance to explore and make music with all of our fun instruments, singing, dancing and educational, fun music games. So much better than a babysitter and watching T.V. all night!

A great, opportunity for your child to get off those screens, interact with other kids, learn new things and make music.

Drop off is at 5:00pm and all participants must be picked up promptly at 8:00pm.

This form is for Friday Night Fun on May 19th. Once you register for one Friday Night Fun, we will save your information and if you wish to sign-up for a future one, all you'll have to do is sign a quick update form.

The next scheduled Friday Night Fun after this one is for June 23rd.

Your information

Parent name *

Address *

City *

State *

Zip code *

Phone number *

Email *

Child information

Child's name *

Age *

Birthdate * +

Does the child have any allergies? If so, please explain. *

Does the child have any behavioral concerns? If so, please explain. *

Dinnertime

What will your child be eating for dinner? *

Choice A - regular wheat crust pizza with dairy cheese and fruit

Choice B - gluten free crust pizza with dairy cheese and fruit

Choice C - I will send a (nut-free) meal for my child to eat

Emergency contacts

Emergency contact name *

Emergency contact phone number *

Relationship to child *

Parent

Neighbor

Friend

Family member (please indicate relationship) Family member (please indicate relationship)

Waiver of Liability

I am an adult over 18 years of age. I acknowledge and grant consent for my child to participate in all Purple Deer Music Academy of Fairfield's Friday Night Fun activities. I understand that even when reasonable precautions are taken, accidents can sometimes happen. Therefore, in exchange for Purple Deer Music Academy of Fairfield allowing my child to participate in Purple Deer Music Academy of Fairfield's Friday Night Fun activities, I understand and expressly acknowledge that I, on behalf of myself, my child, and my child’s next of kin, legal representatives and assigns, do hereby waive and release from liability and covenant not to sue Purple Deer Music Academy of Fairfield, its directors, staff members, students, affiliates, volunteers and guests, and any other person acting for or on behalf of Purple Deer Music Academy of Fairfield, for any loss, damage, or claim of any type, both present and future, including but not limited to, negligence, loss or damage to personal property, personal injury, illness, accident, death, medical costs and any other claims arising out of or relating to my child’s participation in Purple Deer Music Academy of Fairfield's Friday Night Fun activities.

I understand that it is my responsibility to inform the director if my child suffers from any allergies, medical conditions or illnesses. I will take responsibility to keep my child home from Friday Fun Night in the event of illness.

Agreement

I have read this form and am voluntarily granting permission for my child to participate in all the Friday Night Fun activities provided by Purple Deer Music Academy of Fairfield.

Signature *

clear

Participation Agreement

As a participant in our Friday Night Fun, your child will learn in a safe and encouraging environment that is based on mutual respect and cooperation. To provide this environment it is important that everyone agrees to the following guidelines. We want every child to have an awesome experience.

Please take a moment to review this with your child.
As a participant at Purple Deer Music Academy of Fairfield's Friday Night Fun, my child agrees to:

Listen
Be kind to others
Use polite and appropriate language
Be willing to take direction and instruction
Stay focused on the activity
Interact and engage with others

Students who cannot comply with the above should not attend Friday Night Fun. Any student who cannot modify their behavior upon our request, we need an early pick up.

I have discussed the above with my child and I agree to the requirements of participation outlined above.

Signature *

clear

Credit Card Authorization and Information

The cost for Friday Night Fun is $60.00. There is a non-refundable registration fee of $15 which will be charged when you sign-up. The remaining $45 will be charged to your card on May 17th. After that, it is non-refundable but may be applied to a future Friday Night Fun as long as we are given 24-hour notice that your child cannot attend. Without 24-hour notice, there are no refunds.

Included in the cost is the pizza dinner, fruit dessert, juice box or water bottle, materials for activities and something to take home.

By signing and entering your card info, you give permission for Purple Deer Music Academy to charge your card as stated above.

Cardholder's signature *

clear

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security code *

Zip code associated with the card *