2015 REGISTRATION FORM - SUMMER CLASSES

Student's Last Name_______________________________First Name______________________________

 

Age________ Date of Birth______________Name of Parent/Guardian_______________________________

 

Address___________________________________City_______________________State_____Zip________

 

Home Phone______________________Work Phone__________________Cell Phone__________________

Parent/Guardian E-mail _________________________________________

First Emergency Contact:______________________Relationship_________________Phone____________

 

Second Emergency Contact:___________________Relationship_________________Phone____________

 

Physician__________________________________________Office Phone__________________________

 

Medical Information: ______________________________________________________________________

 use reverse side of form if necessary - medical problems, allergies, etc. that we should be made aware of.

 

Pick Up Information:

 

The following adults are authorized to pick up my child from Little Theatre classes.

 

Name_________________________________________________Phone___________________________

 

Name_________________________________________________Phone___________________________

CLASS IN WHICH YOU ARE ENROLLING YOUR CHILD
FEES YOU ARE PAYING
________________________________________
_____________
________________________________________
_____________
________________________________________
_____________
________________________________________
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PAYMENT METHOD
CARD #
NAME ON CARD
EXP
Visa Mastcd Discover ______________ _____________________ ______
Cash    
TOTAL AMOUNT PAID ______________ Sig __________________

Parent/Guardian sign below and mail completed form with payment to Little Theatre, PO Box 114, NSB FL 32170

WAIVER 

I hereby authorize my child to participate in activities sponsored by the Little Theatre of New Smyrna Beach. In case of accident requiring medical treatment, I authorize my child to receive such treatment, as the attending personnel deem appropriate. I also agree not to hold the Little Theatre of New Smyrna Beach or persons acting on its behalf responsible for injuries suffered by my child during activities sponsored by the Little Theatre of New Smyrna Beach. In consideration of the Little Theatre of New Smyrna Beach’s acceptance of my child's enrollment, I hereby waive and release any and all rights and claims to damage against the Little Theatre of New Smyrna Beach. I grant full permission to the Little Theatre of New Smyrna Beach to use any photos or videos of my child and his/her theater work for promotional purposes. I understand that the non-refundable tuition is due in full with the complete application. I understand that the Little Theatre of New Smyrna Beach facilitators have the right to dismiss any student for any serious misbehavior and that I will not be entitled to a refund of tuition. By signing this form, I acknowledge that I have read and understand the above policies. This agreement is a legally binding instrument when signed by registrant and accepted by the Little Theatre of New Smyrna Beach.

Parent/Guardian Signature_______________________________________________Date______________

Please make check payable to Little Theatre of New Smyrna Beach.
rev 1202-01