Broadway Bound Online Registration

Online Application

The online form below offers fields for up to 3 students (of the same family) and general family information. Please fill out all applicable information and click Submit.  You will then be directed to a secure payment portal for submission of each application’s registration fee.

If you need to register more than 3 students, register students for different class options, or would just prefer to register with a paper application and check, visit the Broadway Bound page to download materials.

If you have any questions, please call the Business Office at (603) 745-6032 or e-mail chollingsworth@jeansplayhouse.com.

Class Option and Number of Students*

Student 1 Information

Student 1 Name*
Student 1 Gender*
Student 1 Date of Birth*
 / 
 / 
Grade Student 1 Entering in the Fall*
Student 1 School*
Student 1 T-shirt Size (Please Specify Youth/Adult) *
Please list any allergies, disabilities or other illnesses that may affect participation for Student 1.

Student 2 Information
(If Applicable)

Student 2 Name
Student 2 Gender
Student 2 Date of Birth
 / 
 / 
Grade Student 2 Entering in the Fall
Student 2 School
Student 2 T-shirt Size (Please Specify Youth/Adult)
Please list any allergies, disabilities or other illnesses that may affect participation for Student 2.

Student 3 Information
(If Applicable)

Student 3 Name
Student 3 Gender
Student 3 Date of Birth
 / 
 / 
Grade Student 3 Entering in the Fall
Student 3 School
Student 3 T-shirt Size (Please Specify Youth/Adult)
Please list any allergies, disabilities or other illnesses that may affect participation for Student 3.

General Information

Parent/Guardian Name*
Parent/Guardian Phone Number*
-
E-mail Address*
Address*
Emergency Contact Name*
Emergency Contact Phone Number*
-
Physician Name*
Physician Phone Number*
-
Medical Insurance Company*
Medical Insurance Policy Number(s)*
Should my child be taken to the hospital for emergency purposes, I hereby grant permission to the attending physician and staff to treat my child with anesthetic, medical, x-ray and surgical procedures as may be deemed necessary or advisable by a medical professional. I understand that in an emergency, Jean’s Playhouse will make every attempt to communicate with me prior to use of this waiver. *
I give permission for my child to be photographed and/or videotaped by Jean’s Playhouse for publicity purposes.*
Do you agree to the Liability Release terms shown to the right of this form? *
Please prove you're human

Jean’s Playhouse
Broadway Bound Program
Liability Release and Agreement Not to Sue

Please check the “I Agree” box in your online application to the left to signify your acceptance of these terms. 

I, the undersigned, hereby express my desire and approval for my, and/or my child’s participation in the Jean’s Playhouse Broadway Bound Program. I acknowledge that such participation will include, without limitation, participation in various types of instruction and activities and the use of Jean’s Playhouse’s equipment and premises. I further acknowledge that participation in the program is voluntary and entirely at my risk and/or that of my child. I agree that having a theatre employee present does not lessen the amount or severity of the risks of these activities. I acknowledge that myself and/or my child’s involvement may include running, jumping, lifting and participation in other recreational activities that carry risk associated with participation and that I, on behalf of myself and/or my child have made a voluntary choice to participate in these activities understanding those risks.

I hereby promise not to bring a claim against or sue RELEASEES, for any reason and under all circumstances, on my behalf and/or on behalf of my child and agree to RELEASE, DEFEND, INDEMNIFY and HOLD HARMLESS JEAN’S PLAYHOUSE, its parent, subsidiary, affiliated and successor companies and their respective officers, directors, employees and agents, hereafter RELEASEES, from ANY AND ALL LIABILITY FOR NEGLIGENCE and personal injury including death, and property damage resulting from RELEASEES’ actions, including but not limited to: personal injury caused by RELEASEES operation of or involvement with the Broadway Bound Program or from my participation or my child’s participation in recreational activities that are in any way related to my participation or my child’s participation in the Broadway Bound Program. I understand that permission to use and/or be present on Jean’s Playhouse’s facilities, equipment and premises is being given to me and/or my child in exchange for the execution of this Liability Release and Agreement Not to Sue.

I consent to the use by the RELEASEES of any pictures (video and print) for commercial purposes, or otherwise, of me and/or my child in connection with the activities of the Broadway Bound Program or Jean’s Playhouse, without restriction as to frequency, duration or medium. I further agree that if any portion of this agreement is determined to be unenforceable by a court of law, all other parts of the agreement shall remain in full force and effect. Further, I acknowledge and agree that all of the provisions of this Liability Release will be in force and survive throughout and after the duration of the program. I have read the above paragraphs and fully understand them.

I understand that this is a RELEASE OF LIABILITY, which will prevent me or any other person from filing suit, or making any other claims for damages in the event of personal injury, death or property damage. I freely and voluntarily enter into this agreement. I intend this text to be interpreted as broadly as permissible by New Hampshire law, and understand that it is not intended to assert any claims or defenses prohibited by law.

As a parent/guardian of the minor named above, I acknowledge that I am authorized to agree to this agreement for the minor. I acknowledge and agree that I have read the foregoing http://premier-pharmacy.com/ release, and that by agreeing to these terms on behalf of the minor, the minor and I agree to be bound by its terms. I hereby agree to INDEMNIFY, DEFEND and HOLD HARMLESS RELEASEES as defined on this form for any claim, suit, expense or loss which arises out of the below-named minor’s participation in the Program or which arises out of the minor’s presence on the RELEASEES premises during the program.

Please check the “I Agree” box in your online application to the left to signify your acceptance of these terms.