CIRCLE ARTS’ K.I.D.s (Klasses In Drama)  PLEASE PRINT CLEARLY!

 

 

CHILD'S NAME _________________________________________________AGE ______________

 

CHILD'S SCHOOL _________________________________________________MALE/FEMALE

 

PARENT'S NAME ___________________________________________________________________

 

MAILING ADDRESS _____________________________________________ ZIP _______________

 

E-MAIL ADDRESS __________________________________________________________________

 

HOME PHONE ____________________________  CELL PHONE ____________________________

 

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PLEASE MAKE CHECKS PAYABLE TO CIRCLE ARTS THEATRE

 

TUITION:  2nd-3rd (1 hour): $110; 4th-8th (hour 15 min): $125; JR Adv* (hour & a  half): $150; Advanced* (2 1/2 hours): $175; Private (1/2 hour): $150  *Note: JR. Adv & Adv. classes are by invitation only

 

Check # __________________  Amount _________________     Date __________________

Check # __________________  Amount _________________     Date __________________

 

 

 

 

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.

 

__________________________________________________

 __________________________________________________________________________________

PICTURE RELEASE

Circle Arts Theatre has my permission to use my child's picture on their website, in brochures, and for any other use directly related to publicity.

 

                                                       ____________________________________________________

 

 

 

 

 

 

 

 

 

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 _________________