Theatre Works Registration

Please enter your student information for Fall 2011 registration

Student Name First Last
First and Last Name of the Student Enrolling
Parent Name First Last
Parent or Guardians Name
Student Age

Student Age at Date of Enrollment
Date of Birth / MM / DD YYYY
Student Date of Birth
Any medical conditions or dietary needs we should be aware of (confidential):

Let us know of anything that may be an issue while attending classes
Contact Information
Address
Street Address

Address Line 2

City

Province

Postal / Zip Code

Country
Phone - (###) - ### ####
Email Address
Emergency Contact Name & Phone Number

Who should we contact during an emergency?
Referred by ..

If you were referred by another parent or student please let us know