Registration Form
Students Name
*
First Name
Last Name
Students Date of Birth
*
-
Day
-
Month
Year
Date
Students Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Email (If over 18)
example@example.com
Contact Phone (If over 18)
Please enter a valid phone number.
Parent/ Guardians Name
First Name
Last Name
Parent/ Guardians Phone Number
Please enter a valid phone number.
Parent/ Guardians Email
example@example.com
Does the Student have any medical conditions? (allergies, physical limitations etc)
*
Yes
No
If yes, please provide details.
I give Perform Chepstow permission to use rehearsal and performance photos and videos of the above student for advertising purposes.
*
Yes
No
I give Perform Chepstow permission to seek medical intervention should emergency contacts be unavailable.
*
Yes
No
Emergency Contact 1
Name
*
First Name
Last Name
Relationship to student
*
Phone Number
*
Please enter a valid phone number.
Emergency Contact 2
Name
*
First Name
Last Name
Relationship to student
*
Phone Number
*
Please enter a valid phone number.
Any other information you feel is relevant to your Childs inclusion in our sessions.
Submit
Should be Empty: