Lyceum Registration - Broadway Theatre League

Student Name(Required)

First Last

Parent/Guardian(Required)

First Last

Registration Type

Students must choose one concentration: Visual OR Performing Arts.

FALL 2024: Performing Arts - Grades 2-5: $125

FALL 2024: Performing Arts - Grades 6-12: $125

FALL 2024: Visual Arts - Grades 2-5: $125

FALL 2024: Visual Arts - Grades 6-12: $125

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

School(Required)

School Name Grade Level for 2024/2025 academic year

Does your child have a medical condition that may affect their participation?(Required)

Yes

Please describe(Required)

Does your child have any allergies?(Required)

Yes

Please list all allergies here.(Required)

Does your child have any limitations that would prevent them from participating in physical activity?(Required)

Yes

Please describe(Required)

Medical Acknowledgement:(Required)

In the event that my child becomes injured or ill during the Lyceum program, I authorize the transportation of my child to a hospital for treatment. If, in the judgments of the Lyceum staff, the illness or injury is sufficiently serious, I understand that a staff member will contact me at the telephone number given below if such treatment is deemed necessary. I understand that I am responsible for ambulance or hospital charges.

I give permission for my child to receive treatment in the event of an emergency.

Self-Administration of Medication:(Required)

I acknowledge that the Lyceum program does not have a nurse on duty at the program and my child will be responsible for self-administration of medication. The NEIU, Broadway Theatre and Ballet Theatre of Scranton are not responsible for the administration of medication.

I acknowledge the above, and will provide a physician's note in the event my child has medication that must be self-administered.

Important Notice for Parents & Guardians

Please remember, as per state law, no medication of any kind can be self-administered by your child at The Lyceum without a written physician’s order. Written permission slips from parents cannot be accepted. Please Print and fill out the form below and mail it to The Lyceum at: lfaist118@gmail.com

>> Download Medication Self-Administration Permission <<

Primary Emergency Contact(Required)

First Last

Primary Emergency Phone(Required)

Secondary Emergency Contact(Required)

First Last

Secondary Emergency Phone(Required)

Photo and Video Release(Required)

In consideration of my son/daughter's engagement as a photo or video subject by the Arts in Education NEPA, Northeastern Educational Intermediate Unit (NEIU) and the Lyceum program, I hereby grant the right and permission to copyright, use, reuse and publish photographs or videotape images made of my son/daughter for the Lyceum program's educational purposes, including use in advertisements for public relations and development purposes. I hereby release NEIU and its authorized representatives, including the photographer or videographer, from any liability by virtue of any blurring, distortion or alteration that may have occurred in the making of such images and from any liability for claims of libel or invasion of privacy for any reason.

I agree to photo and video release.

Regulations(Required)

My child agrees to abide by all programs and regulations while attending Lyceum programs. We understand that the possession or use of alcoholic beverages, unauthorized drugs or a weapon of any kind is grounds for immediate expulsion from the program. We also understand that disruptive behavior will result in immediate dismissal. Refunds are not granted if my child is dismissed from the program.

I have read and understand the regulations.

Lost or Stolen Articles(Required)

I understand that NEIU, Broadway Theatre League of Northeast PA, Ballet Theatre of Scranton, Afa Gallery, and the Everhart Museum are not responsible for any lost or stolen articles.

I have read and understand Lost and Stolen Articles.

Parental Consent(Required)

I understand that during the course of the program the students will be in various locations for periods of time, but fully supervised as they participate in the program. I understand that daily attendance is mandatory and that the only excusable absence would be for medical reasons.

I give my permission for my son/daughter to attend the Lyceum program.

How Would You Like To Pay?(Required)

Secure Credit Card

Mail Us A Check

I have a scholarship discount code.

Scholarship Discount Code

Please make checks payable to Broadway Theatre League and mail them to: 345 N Washington Ave. Scranton, PA 18503 Please note: Your registration is not confirmed until you receive a confirmation notice from Broadway Theatre League.

All refunds will be distributed as credit for future Lyceum Programming.

REGISTRATION FORM

Important Notice for Parents & Guardians