Student Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

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Cell Phone *

(###)

###

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Work Phone *

(###)

###

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Emergency Contact Phone *

(###)

###

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Are there any allergies, medical conditions, or disabilities we need to be aware of? *

Yes

No

Parental Authorization *

I hereby waive and release any and all claims for damages, injuries or death that may be suffered before, during or after activities with RTK. I will further hold harmeless Riverside Theatre for Kids and Riverside Theatre. I hereby authorize any physician, trainer, or nurse selected by RTK personnel to order and contact any emergency medical or surgical procedures necessary to safe life and limb. I understand and give permission for my child to be filmed for TV or photographed. I acknowledge that my child will abide by RTK's posted rules and regulations. Furthermore, I hereby grant RT the absolute right and permission to make, reproduce, broadcast or otherwise use participant’s name and likeness, any photograph, films, videos, recordings, or other depictions or images in whatever form or media in connection with participation in the Riverside Theatre.

REFUND POLICY *

Refund Policy: Tuition is refundable up to three days before the first day of each class less a $15 cancellation fee. A 50% refund less a $15 cancellation fee will be given up to the second day of class. There will be NO REFUNDS after the second day of class and full tuition will charged as well as a $15.00 cancellation fee.

I have read and understand the refund policy.