Daytime Moon Creations Theater Program Application

Please complete this form to apply for the Daytime Moon Creations Theater Program at the Berklee Institute for Arts Education and Special Needs (BIAESN). Applications will be reviewed by our team, and Dr. Rhoda Bernard, BIAESN's managing director, will contact you directly to arrange a follow-up meeting and/or phone call.

For questions or for more information, please contact Bernard by email at or by phone at 617-747-2760.

Thank you for your interest in our program. We look forward to meeting you soon.

Student Information
Students in the Daytime Moon Creations Theater Program must be no younger than age 9 and no older than age 15.
Colleges and universities are often asked by the federal government, accrediting associations, college guides, newspapers, and our own college/university communities, to describe the racial/ethnic backgrounds of our community members. In order to respond to these requests, we ask you to answer the following question:
All students in the Daytime Moon Creations Theater Program must have a diagnosed disability. Students who do not have a diagnosed disability cannot participate in this program.
Family Information
Participation is dependent on acceptance to the program and availability.
Program Information
By typing my name in the field below, I, for myself, for my child, do hereby release Berklee College of Music and its principals, trustees, directors, officers, agents, employees, and the staff and instructors from the Institute for Arts Education and Special Needs from all liability with respect to my child, and I waive any claim for damages arising from any cause whatsoever, including but not limited to claims that my child was less than successful in the Daytime Moon Creations Theater Program.
By typing my name in the field below, I hereby consent to and authorize Berklee College of Music and/or any of its vendors and their representatives to use still photographs, video footage, and audio recordings of my child in films, video, and audio presentations for associated nonprofit purposes, including a documentary film designed to promote public awareness and education about autism, and for fundraising purposes. I hereby waive any rights to privacy or compensation regarding my authorized release of this video and audio material, and I agree to hold Berklee College of Music harmless from any and all claims relating to my authorized release of said material. I understand that usage of the video/audio may be seen/heard by the general public on our website(s) and in public or private screenings, and I understand that Berklee College of Music has full and complete rights to those images.
Student Code of Conduct
All students are expected to abide by the Student Code of Community Standards. Due to the age range of students involved in summer programs, there are additional policies in effect that are designed and enforced to ensure the safety and wellbeing of the students participating. ABLE Day Sessions students must abide by the following policies: 

1. Possession and/or use of alcoholic beverages is prohibited, regardless of age. It is also a violation to be in the presence of or under the influence of alcohol and/or drugs while at ABLE Day Sessions. 

2. Sexual activity is prohibited while participating in the program. Any activity which is a violation of Massachusetts General Law c.265, s.23 (commonly known as the Statutory Rape Law), regarding statutory rape and abuse of a child, is unlawful and in violation of the standards. Also, please understand that by law we may be required to report this behavior to state authorities and such behavior may also be grounds for immediate dismissal from the program without reimbursement of tuition and fees. Please note that in Massachusetts this defines a child as someone under the age of 16.
3. Participants must abide by the checkin policies as prescribed by their program.
Violations of these standards will be investigated swiftly and may lead to immediate removal from the program without reimbursement of fees, as well as parental notification. There is zero tolerance for violations of the alcohol and drug policy, and such violations will result in removal from the summer program.
Participant Waiver, Assumption of Risk, and Publicity
This is a release of liability and assumption of risk agreement. Read it carefully before signing. In consideration for being permitted to participate in Berklee College of Music ("Berklee") Summer Programs (the "Program"), the receipt and sufficiency of which is hereby acknowledged, I agree as follows:
(1) Voluntary Participation and Assumption of Risk. I understand and confirm that my participation in the Program is voluntary and I fully understand and appreciate the dangers, hazards, and risks inherent in the Program and in any independent travel or activities I may undertake as an adjunct to the Program, including but not limited to, property damage, bodily injury, personal injury, and death. I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation in the Program and accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in the Program.
(2) Release, Waiver, and Indemnity. I hereby waive, release, forever discharge, and covenant not to sue Berklee and its directors, officers, trustees, employees, agents, volunteers, successors, and assigns, from any and all liability for and waive any and all claimes for injury, loss, or damage of any type, including attorneys' fees, in any way connected with my participation in the Program, whether or not casued in whole or part by the negligence of Berklee or any of the individuals mentioned above. I further agree to save and hold harmless, indemnify, and defend the College from any claim by me or my family, arising out of my participation in the Program. I also agree to hold Berklee harmless from any loss, liability, damage or cost that Berklee or any third party may incur due to my participation in the Program.
(4) General Provisions. This Agreement shall be governed by the laws of the Commonwealth of Massachusetts, USA, regardless of where the Program takes place. I agree to submit to the exclusive jurisdiction of the state and federal courts of the Commonwealth of Massachusetts to resolve any disputes arising herunder or related in any manner to my participation in the Program(s). I agree that this Agreement is intended to be as broad and inclusive as permitted by law. The terms and provisions of this Agreement shall be severable, such that if any term is for any reason held to be unenforceable or in conflict with any law applicable to this Agreement, the validity of the remaining portions shall not be affected. This Agreement constitutes the entire agreement pertaining to the subject matter and no oral representations, promises, or inducements not expressly contained herein have been made.

I have read the foregoing before affixing my name below, and warrant that I fully understand the contents thereof.

Emergency Contact Information: Contact I
Provide contact information for an individual in case of an emergency.
Emergency Contact Information: Contact 2
Healthcare Provider Information
Medical Insurance
Medical History
Please note: Our staff cannot administer any medications, prescription or nonprescription, to program attendees. The program nurse may administer nonprescription medications, such as Advil or Tylenol, only after speaking with a parent or guardian. If the attendee will need to take prescription medications while attending the program, they must assume responsibility for taking the medication as needed or indicated. Please indicate your permission for your child to self-administer the medication(s) listed above by signing this form. 
By signing, I certify that the above-named student is physically fit to participate in a Berklee program. The health information provided on this form is correct to the best of my knowledge.