Point Breeze Performing Arts Center

Future Home of PBPAC

We are well on our way with the Capital Campaign.

1717-21 Point Breeze Avenue, Philadelphia, PA 19145-1932 215-755-1014

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Registration Form

Program Registration

Register you child for the 2005/2006 season today! Enrolling in Point Breeze Performing Arts Center (PBPAC) is a wonderful opportunity to dive head-first into the exciting world of the performing arts. PBPAC is committed to providing learning and performance experiences for students of all ages and ability levels. We afford our participants challenges that inspire the human spirit to realize its greatest potential. We demand excellence from students by encouraging their exploration of artistically demanding experiences, while simultaneously nurturing their self confidence.

You can register here or in person at our main location at 1717-21 Point Breeze Avenue.

Now through September 9: $ 25 per child, $ 40 per family
September 12 through February 25: $ 35 per child, $ 50 per family

PBPAC does not discriminate according to race, color, religion, national origin, or physical disability.

Student Last Name *
First Name *
Middle Initial
Mailing Address *
City *
State *
Zipcode *
School Name *
School Phone No.
Current Grade *
Age *
Date of Birth *	Enter any relevant date format, i.e. (mm/dd/yyyy) or Jan xx, 19xx
Race/Ethnicity
Gender *
Parent/Guardian Last Name *
First Name *
Middle Initial
Mailing Address *
City *
State *
Zipcode *
Relationship to Student *
Home Phone No.
Work Phone No.
E-mail Address
Annual Household Income
Emergency Contact Last Name *
FIrst Name *
Middle Initial
Mailing Address *
City *
State *
Zipcode *
Relationship to Student *
Home Phone No. *
Work Phone No. *
Special Needs / Concerns / Medication	Please specify any and all special needs/concerns/medication related to your child's participation in PBPAC's program, which involves physical activities and exercises. PBPAC is not responsible for the administration of any medication.
How did you hear about PBPAC?
*	I understand that after three consecutive unexcused absences from class, my child may be dropped from class and may have to re-register for the following semester.
*	I understand that I must communicate in writing reasons for absences in order for my child to be excused for absences.
*	I understand that if I wish to withdraw my child from PBPAC, I must express this wish to withdraw in writing.
*	I understand that PBPAC operates under the assumed risk clause. Attendance is at the individual\'s own risk. PBPAC is not responsible for injuries sustained inside or outside of the building or because of mishaps in classes, dressing rooms, and other PBPAC-used sites due to inappropriate behavior on the part of the student.
*	I understand that if I choose to leave my child at PBPAC outside of the specific time of the classes for which he/she is registered, I do so at my own risk.
*	I understand that PBPAC is not responsible for any valuable items lost or stolen on the PBPAC\'s premises or during PBPAC\'s activities. I understand that students are strongly encouraged to leave all valuable items and large sums of money at home.
*	I understand that if I choose to allow my child to associate with an employee, family, or child of PBPAC outside of the business of PBPAC, I do so at my own risk.
*	I, as the parent/legal guardian of the student named john smith hereby grant permission for my child/ward to be photographed, videotaped, and/or interviewed during the course of his/her involvement in PBPAC and any of its authorized agents. I consent to the publication, broadcast, or other use of my child’s/ward’s images and/or words for the purposes of promoting PBPAC. In addition, I intending to be legally bound for myself, my heirs, executors, and administrators release PBPAC, or any parties acting on their behalf and with their approval, from liability for such uses of my child’s/ward’s images and/or words.
*	I have read this student registration form in its entirety and fully understand my responsibilities and the conditions of participation set by PBPAC.

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