CIRCLE ARTS’ K.I.D.s (Klasses
In Drama)
CHILD'S
NAME _________________________________________________AGE ______________
CHILD'S
SCHOOL _________________________________________________MALE/FEMALE
PARENT'S
NAME ___________________________________________________________________
MAILING
ADDRESS _____________________________________________ ZIP _______________
E-MAIL
ADDRESS __________________________________________________________________
HOME
PHONE ____________________________
CELL PHONE ____________________________
*************************************************************************************
PLEASE MAKE CHECKS PAYABLE TO CIRCLE ARTS THEATRE
TUITION: Total: $125 for 1 week, $225 for 2 weeks; $25 deposit to be mailed in; remainder due on first camp day
Check #
__________________ Amount
_________________
Date __________________
Check #
__________________ Amount
_________________
Date __________________
PLEASE CIRCLE ONE: Camp Time: 9am-12pm or 1pm-4pm Camp Length: 1 week or 2 weeks
RELEASE FORM
5
My child ________________________ has
my permission to come outside to my car after class has been dismissed.
__________________________________________________
5
I wish my child
____________________________ to remain in the building after class has been
dismissed and I will come in to get him/her.
__________________________________________________
CIRCLE ARTS THEATRE
Personal Medical History & Medical
Release
PLEASE
PRINT!
NAME ________________________________________________________
DATE OF BIRTH _____________________________ AGE _______ SEX _________
ADDRESS _________________________________________________________________________
CITY _______________________________________ STATE __________ ZIP ______________
HOME PHONE ______________________________ CELL PHONE _______________________
EMAIL _____________________________________ WORK PHONE ______________________
HEALTH INSURANCE
CARRIER
NAME ____________________________________
GROUP # _____________________________
ADDRESS
_________________________________________
SUBSCRIBER # ________________________
PHYSICIAN(S)
PHONE
ADDRESS
____________________________________________
______________________________________________
___________________________________________________________________________________________
CURRENT MEDICATIONS
DRUG ALLERGIES
FOOD/OTHER ALLERGIES
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Does
your child have any other special needs or medical conditions of which we should
be aware?
_______________________________________________________________________________________________
EMERGENCY CONTACTS
RELATIONSHIP
HOME PHONE
CELL PHONE
______________________________________________________________________________________________
______________________________________________________________________________________________
WAIVER OF LIABILITY & MEDICAL TREATMENT AUTHORIZATION
I do hereby appoint CIRCLE ARTS
THEATRE to act on my behalf in regards to my child
______________________________, in the event that I cannot be contacted, to
authorize or refuse necessary emergency treatment while my child is
participating in class and related events.
I understand and agree that I will be responsible for the payment of
all costs incurred incident to such treatment.
I will not hold CIRCLE ARTS THEATRE or its Staff Members in any way
responsible for accidents and/or injury to the child that are wholly or in
part resulting from participating in class events.
NAME
________________________________ SIGNATURE
__________________________________
DATE _________________