2012 REGISTRATION FORM - SPRING BREAK CAMP
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Student's
Last Name_______________________________First Name______________________________ Age________
Date of Birth______________Name of Parent/Guardian_______________________________ Address___________________________________City_______________________State_____Zip________ Home
Phone______________________Work Phone__________________Cell Phone__________________ Parent/Guardian E-mail _________________________________________ First Emergency Contact:______________________Relationship_________________Phone____________ Second Emergency Contact: Physician__________________________________________Office
Phone__________________________ Medical
Information: ______________________________________________________________________ Pick Up Information: The
following adults are authorized to pick up my child from Little Theatre
classes. Name_________________________________________________Phone___________________________ Name_________________________________________________Phone___________________________
Parent/Guardian sign below and mail completed form with payment to Little Theatre, PO Box 114, NSB FL 32170 |
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I
hereby authorize my child to participate in activities sponsored by
the Little Theatre of New Smyrna Beach. In case of accident requiring
medical treatment, I authorize my child to receive such treatment, as
the attending personnel deem appropriate. I also agree not to hold the
Little Theatre of New Smyrna Beach or persons acting on its behalf responsible
for injuries suffered by my child during activities sponsored by the
Little Theatre of New Smyrna Beach. In consideration of the Little Theatre
of New Smyrna Beach’s acceptance of my child's enrollment, I hereby
waive and release any and all rights and claims to damage against the
Little Theatre of New Smyrna Beach. I grant full permission to the Little
Theatre of New Smyrna Beach to use any photos or videos of my child
and his/her theater work for promotional purposes. I understand that
the non-refundable tuition is due in full with the complete application.
I understand that the Little Theatre of New Smyrna Beach facilitators
have the right to dismiss any student for any serious misbehavior and
that I will not be entitled to a refund of tuition. By signing this
form, I acknowledge that I have read and understand the above policies.
This agreement is a legally binding instrument when signed by registrant
and accepted by the Little Theatre of New Smyrna Beach. Parent/Guardian
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