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:*

Acknowledge and Agree to Registration Terms

Read & review CTC Education & COVID-19 Policies

I understand and accept the Medical Policy

Yes

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*

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.

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Theatre Arts Training Emergency Contact Form

Student Information

Parent/Guardian Information

2nd Parent/Guardian Information

Alternate Contact

Medical Information

Acknowledge and Agree to Registration Terms