MEAN GIRLS WORKSHOP WITH DONNA CERIO ENROLLMENT FORM
STUDENT INFORMATION
Last Name *
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First Name *
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Age *
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Grade *
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PARENT INFORMATION
Parent Name (Primary Contact) *
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Parent Name (Other Parent/Guardian)
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Primary Phone (XXX-XXX-XXXX) *
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Phone (Home or other Parent/Guardian)
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Student Phone
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Email (Primary Contact) *
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Email (Other Parent/Guardian)
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Student Email
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School
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Street Address (Primary) *
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Town *
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Zip Code *
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Street Address (Other Parent/Guardian, if different from above)
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Town
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Zip Code
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EMERGENCY CONTACT INFORMATION
(OTHER THAN PARENT)
E.C. First Name *
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E.C. Last Name *
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E.C. Phone (XXX-XXX-XXXX) *
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E.C. Relation to Child *
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PAYMENT INFORMATION
If paying by check, our mailing address is as follows.

23 Elephants Theatre Company
PO Box 1939
San Anselmo, CA 94979
MEAN GIRLS WORKSHOP enrollment fee is $350. Please select one of the following options: *
CONFLICTS
Please list any conflicts that you may have with the rehearsal or performance schedule. *
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MEDICAL AUTHORIZATION/PHOTO & VIDEO RELEASE
By checking this box, I hereby agree to indemnify and hold harmless 23 Elephants Theatre Company and its officers and employees from and against any and all liabilities for any injury which may be suffered by me or my child arising out of or in any way connected with participation in the program noted above. In case of an emergency, my child may be treated by a qualified physician. I give 23 Elephants Theatre Company permission to use photographs and/or videos of my child in brochures or publicity. *
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REFUND POLICY
If there is insufficient enrollment, the production/ class will be cancelled and your money refunded. Withdrawal from the production/class will incur a $125 fee. Withdrawal requests must be made by the first day of the production/class. THERE WILL BE NO REFUNDS AFTER THE FIRST DAY OF THE PRODUCTION/CLASS. *
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