Theatre Arts Training Emergency Contact Form

Student Information

Student Name*

First Last

Student Date of Birth*

Parent/Guardian Information

Parent/Guardian Name*

First Last

Email*

Day Phone*

Evening Phone

Address*

Street Address Address Line 2 City State ZIP Code

Add a 2nd Parent/Guardian?

Yes

If yes, an account will be verified/created

2nd Parent/Guardian Information

Parent/Guardian Name*

First Last

Email*

Day Phone*

Evening Phone

Same address as Parent/Guardian #1*

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Alternate Contact

(If we are unable to reach a contact listed above)

Alternate Emergency Contact #1*

First Last

Relationship to Student*

Alternate Emergency Contact #1 Phone*

Alternate Emergency Contact #2

First Last

Relationship to Student

Alternate Emergency Contact #2 Phone

Alternate Emergency Contact #3

First Last

Relationship to Student

Alternate Emergency Contact #3 Phone

Are there any individuals who are NOT authorized to pick-up the student?

Yes

If yes, please list names.

Please list names of any individuals not authorized to pick up the student

Medical Information

The student is covered by a medical insurance/assistance plan*

Yes
No

Medical Insurance/Assistance Provider

Policy Number

Does the student have special considerations, learning needs, allergies, or medications that we should be aware of?*

Yes
No

(please include any food allergies and/or bee stings)

Please explain:*

Demographic Information

Which of the following best describes your student?*

Tell us more!*

If additional information regarding ethnicity feels relevant for your student, feel free to share below. (Ex. Hispanic, Egyptian, Dominican, Somali, Pakistani, etc.)

Acknowledge and Agree to Registration Terms

Read & review CTC Education & COVID-19 Policies

Hidden

I understand and accept the Medical Policy

Yes

Hidden

I have read and accept CTC's Education Policies

Yes

I have read and accept CTC's Education Policies.*

Yes

I have read and accept CTC's COVID-19 Safety Policies.*

Yes

Photo Release*

For virtual sharings, photos and videos of students may be captured to share with camp families. These photos and videos will not be shared publicly unless permission is given below.

Yes, I give my permission for photos/videos of my child(ren)'s participation in CTC Education Programs to be used for promotional or grant development needs.
I DO NOT give permission for photos/videos of my child(ren) to be used for promotional or grant development needs. I understand photos and videos of my student will be taken and shared privately with families in individual camps as part of the celebration of the students work.

Comments

This field is for validation purposes and should be left unchanged.

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Theatre Arts Training Emergency Contact Form

Student Information

Parent/Guardian Information

2nd Parent/Guardian Information

Alternate Contact

Medical Information

Demographic Information

Acknowledge and Agree to Registration Terms