Student's first and last name: (required)
Preferred Name (for Name Tag):
Student's Age: (required)
Student's Year in School:
Gender: (required) MaleFemale
Does this student have a disability, special needs or allergies? (required)
If YES, please describe this student's disability or special need. (ADD, ADHD, Asperger's, Sensory Issues, Developmental Delay, Epilepsy, etc) We can best help your student succeed if we know his/her background.
Email Address: (required)
Best Phone (XXX-XXX-XXXX): (required)
Alternate Phone: (required)
I hereby release the ACT, its agents and employees from any and all claims and liabilities resulting from participation with ACT sponsored activities. In the event of an emergency, I understand that a reasonable effort will be made to contact me in regards to my child. If I cannot be reached, I hereby authorize an agent of the Academy of Children’s Theatre (ACT) to act on my behalf to seek emergency medical treatment for me or my child, listed above, in the event that such treatment is deemed necessary by that agent. I authorize the physician selected by said agent to administer such emergency treatment as said physician deems necessary (in his/her judgment) under the circumstances. I understand and agree that I will be responsible for payment of said physician's fee and any and all other fees or expenses associated with such treatment.
Parent Signature - by filling in your name, you confirm that you agree to the medical release and have the legal right to sign for your medical treatment or the afore mentioned minor.
Unless informed otherwise in writing, the Academy of Children's Theatre (ACT) considers photographs and recordings (film, video, digital, etc.) taken of students and their work in class and in performance to be permissible for publication in ACT marketing materials and in informational publications, including our website.
I understand that this tuition is non-refundable.