First Name of Actor *

Last Name of Actor *

Date of Birth *

School Actor Attends *

Gender *

Age *

Actor's Home Address *

Zip Code *

Who does actor live with? *

Name of person registering Actor *

Your email address *

Your phone number *

Second Parent or Guardian *

Best phone number for this parent *

Second parent Email address (if different from yours) *

Please list an emergency contact, in case parents and/or guardians cannot be reached. Parents are always contacted first. *

Emergency contact's relationship to your child. *

Emergency contact's best phone number. *

Health Insurance carrier *

Policy # *

Doctor and Medical Group *

Doctor and Medical Group's phone number *

Does your child have any medical conditions, allergies, or special needs that the directors should to be aware of? *

If so, please list

What information or special equipment do we need while your child is in our care? *

Would you or a family member be willing to volunteer? *

What is your name? *

Will you pay tuition by check or online at Square? *

I understand that payment for the tuition of $550 must be made before enrollment is complete. *

I confirm that all information is correct and complete. *

Electronic Signature By checking "I agree" I affirm consent, and agree that: My electronic signature on this form above the same effect as if I signed this form in ink. *

Your legal name *

I am enrolling my child for 2020 Summer Theatre. Session dates will be posted soon at La Colina Jr High. Two-week session, 9 am to 2 pm. Two performances on the second Friday. sbshowstoppers@gmail.com or call (805) 314-1221 for payment information *