Mill Mountain Theatre Student Liability Waiver Form | Fall 2017
Please fill out the below inquiries
Student's Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Gender Identity *
School *
Your answer
Grade *
Parent(s)/Guardian(s) Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone (Parent/Guardian) *
Your answer
Email (Parent/Guardian) *
Your answer
Phone (Student) (If applicable)
Your answer
Emergency Contact Name AND Relationship to Student *
Your answer
Emergency Contact Phone *
Your answer
Allergies/Other Healthcare Needs *
Your answer
Any Special Learning/Developmental Needs we should know about?
Your answer
Insurer *
Your answer
Insurance Policy # *
Your answer
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