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Libertyville Broadway Bound
Tuesdays and Thurdays 6:00 - 7:30pm
IP Blackbox Theatre - 735 N Milwaukee Ave, Libertyville, IL 60048
Student's Name (First, Last):
Parent/Guardian (First, Last) (*if guardian, please include your relationship):
Parent's/Guardian's Primary Phone Number:
Parent Guardian's Secondary Phone Number:
Emergency Contact Name:
Emergency contact Relationship to Student:
Emergency Contact's Secondary Phone Number:
Please list all student allergies and necessary medical supplies i.e. EPI-Pen etc. (even minor allergies, better safe than sorry!):
Please list any/all medical information or behavioral health information for your student:
Please provide your mailing address below:
Any other questions or concerns you would like to make the IP Staff aware of? Please let us know! We are happy to read and help answer any necessary questions/concerns/comments.
T-Shirt Size (Youth Sizes)
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