Complete this registration form to sign up for in person Play Me a Story.
After clicking submit, you will be asked to select the date you wish to attend and then complete your payment information. Thank you.
Caregiver First name
*
Caregiver Last name
*
Email
*
Phone number
*
Student 1 - name
*
Student 1 - date of birth
*
---
January
February
March
April
May
June
July
August
September
October
November
December
---
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
---
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Student 2 - name
Student 2 - date of birth
---
January
February
March
April
May
June
July
August
September
October
November
December
---
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
---
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Does your student(s) have any communication, mobility, or other needs that you would like us to know about?
Allow PS to use my childs photo video audio
*
Yes, can use in marketing
No, do not use in marketing
Release
*
I understand these activities may include certain risks including, but in no way limited to: (1) moderate & severe personal injury, (2) property damage, (3) disability, (4) death, & (5) sickness or disease including, without limitation, COVID-19.
Release
*
I specifically release Education, its owners, directors, employees, & volunteers from any claim of any kind arising from my student’s participation in the Education program.
*
= required field
