Enrollment Form

CHILD'S INFORMATION

* Indicates required field

Name of Child *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

School *

Grade as of 2017-2018 *

PARENT(S) INFORMATION

Mother's Name *

First

Last

Mother's Email *

Mother's Cell *

Mother's Office *

Father's Name *

First

Last

Father's Email *

Father's Cell *

Father's Office *

MEDICAL INFORMATION

Emergency Contact Name *

First

Last

Relationship *

Home Phone *

Cell *

Doctor's Name *

First

Last

Doctor's Phone Number *

Insurance Company *

Policy # *

My Child May Be Given *

Tylenol Advil Tums

Medications Being Taken *

Medical/Allergy, Social/Emotional issues that you feel our staff should know *

CARPOOL CONTACTS

My child may be picked up by the following people (other than parent/guardian)

Carpool Pickup #1 Name *

First

Last

Carpool Pickup #1 Home Phone *

Carpool Pickup #1 Cell *

Carpool Pickup #2 Name *

First

Last

Carpool Pickup #2 Home Phone *

Carpool Pickup #2 Cell *

PARENT AGREEMENT

There are no makeup days or refunds for absence due to sickness or other reasons.
There are no sessions on July 2nd, 3rd, and July 4th.
I will bring my child to the workshop by no later than 9:00am and pick him/her up promptly at 3:00pm.
I will provide 2 snacks, lunch, and water each day (no shellfish, pork, or nuts).
I authorize Broadway Kids LA to use any photographs or videos taken in promotion, marketing, program materials, and media.
To ensure my child's space, a $400 non-refundable deposit, along with this Enrollment Form and Permission Agreement, is required. The remaining tuition balance is due by April 20, 2018.
For enrollment after April 20th, only FULL TUTION is accepted.
Tuition is no longer refundable after April 20, 2018.
I understand that casting decisions are made by the Directors and are final. I support the casting decisions made by the Directors.

By entering your name and date below, you acknowledge that you have read, understand, and accept the policies stated above.

Name *

Date *

Submit

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