Account Information (Name of Parent/Guardian)

Last name (Parent):* First Name (Parent):*

Street Address: City: State: Zip:

Home Phone # * Cell Phone #:

Email address: *

Your Place of Employment Phone Number:

Other Parent's Name:

Home Phone # Cell Phone #:

List two Emergency Contact Persons/Phone Numbers:
Emergency contact #1 Name: Phone number:

Emergency contact #2 Name: Phone number:

Student Information

Last Name:* First Name:* Age:* D.O.B.*

Last Name: First Name: Age: D.O.B.

Last Name: First Name: Age: D.O.B.

School/Grade:

Medical Conditions:

Class Name: Class Day/Time:

Class Name: Class Day/Time:

Class Name: Class Day/Time:

Please list people authorized to take your child from our facility:

How did you hear about us?

Yellow pages    Web   Newspaper    Brochure   Sign

Other:

 * = Required items

Read the following:
By checking the box below, you agree and understand the terms and rules of Stage Door Studios. You agree to pay tuition and all fees by the 15th of each month and any money not turned in by its deadline will have a $15 late fee added. You also understand that if your check is returned for any reason, you will owe that money plus a $35 return check fee. If at any time your child will not be coming back to classes, you MUST fill out a drop form and notify the office to make room in the class for other students, all money is still due until this is done. All monies paid in advance are non-refundable. Activities at Stage Door Studios are physical and with all physical activities injuries are possible, you understand and will not hold Stage Door Studios or anyone in it responsible for any injury or loss that may occur. When sending your child to Stage Door Studios you understand that they are covered by your own insurance and will not hold Stage Door Studios responsible.  I give Stage Door Studios permission to consult the physician named below (or the health resource) in case of an emergency if I cannot be reached. I also accept the responsibility for the cost of the above medical services. By signing this you give your child permission to participate at Stage Door Studios and allow their name and/or photos to be used for ads, display or studio use.
By checking this box, I agree and understand the terms and rules of Stage Door Studios

By checking this box, I hereby give permission to Stage Door Studio/preschool to use images of my child for advertising and promotion of their business.

I do hereby allow to fully participate in this program

Parent/Guardian name:* Date:

Physician's Name: Physician's Number:

Hospital of choice: