Custom Broadway Youth Week '20 Registration Form
Welcome to Custom Broadway! Youth Week takes place June 22-26, 2020 in NYC's theatre district.
Please contact us at (917) 584-7618 or SueGilad@gmail.com if you make an error and need to submit another response.
Name of Participant (First and Last) *
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Participant Date of Birth *
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Participant Email *
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Participant Phone *
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Parent Full Name
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Parent Email *
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Parent Phone *
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Emergency Contact Name and Phone
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Does the Participant have any restrictions or prohibitions on physical activity? (If yes, please explain.)
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Does the Participant have a current physical or mental condition that may affect participation? (If yes, please explain.)
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Please provide any additional information which may be relevant concerning the current health of the Participant.
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Does the participant take medication? (If yes, please specify.)
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Medical Insurance: Company Name, Plan # and Group #
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Dietary Restrictions?
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Allergies?
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Has the Participant had surgery or serious injury? (If yes, please explain.)
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Anything else you would like us to know?
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By checking the box, you acknowledge that all the information is true and accurate.
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