Fall Class Registration and EMF

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Class Registration and Emergency Medical Form, If enrolling multiple children, please fill out one form per child.

Email *

Class Registration *

Musical Theatre Melody: Hard Knock Life (ages 5-8) $175

Musical Theatre Melody: Disney Showtunes (ages 9-11) $175

Stage Combat and Shakespeare (ages 12-18) $175

Required

Child's Name *

Date of Birth

YYYY

Parent or Guardian name (if under 18) *

Cell Phone/Home Phone *

Alternative Emergency Contact Name

Alternative Emergency Contact Phone#

Hospital/Clinic Preference

Hospital/Clinic Phone Number

Please list any allergies to food and/or environmental allergies.

Please list any medical or health concerns

I authorize medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive the right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency *

Yes, I authorize emergency consent

I grant permission for my photo to be taken by Rubber City Theatre, with the understanding that this photo might be used for marketing purposes. *

Yes

Electronic Signature (Parent or Guardian if under 18) *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Rubber City Theatre. Report Abuse

Forms