Student's First and Last Name: *

Preferred Name (for Name Tag)

Age: *

Gender Male Female *

Are you a NEW or RETURNING student to ACT? Please select one New Student Returning Student Returning Student MOVING UP from Ages 4-6 into Ages 6-9 *

Returning Students: Have you lost your binder? Please select one Yes, I need to order a NEW binder for $5 No, I do not need a new binder

Does this student have a disability or special needs? Please select one No Yes *

If YES, please descibe this student's disability or special need. (ADD, ADHD, Asperger's, Sensory Issues, Developmental Delay, Epilepsy, etc) We can best help your child succeed if we know his/her background.

Spring Break Camp: Ages 6-9 Camp Selection AGES 6-9 Spring Break Musical Theatre

Spring Break Camp: Ages 9-12 Camp Selection AGES 9-12 Spring Break Acting Camp Spring Break Musical Theatre Camp

Spring Break Camp: Ages 13-19 Camp Selection AGES 13-19 Spring Break Musical Theatre Camp

Parents' Names: *

Street Address: *

City: *

State: *

Zip: *

Best Phone: *

Alternate Phone (Do NOT list the same number again): *

E-mail Address: *

In the event of an emergency, I understand that a reasonable effort will be made to contact me. If I cannot be reached, I hereby authorize an agent of the Academy of Children’s Theatre (ACT) to act on my behalf to seek emergency medical treatment for my child, listed above, in the event that such treatment is deemed necessary by that agent. I authorize the physician selected by said agent to administer such emergency treatment as said physician deems necessary (in his/her judgment) under the circumstances. I understand and agree that I will be responsible for payment of said physician's fee and any and all other fees or expenses associated with such treatment. I hereby release the ACT, its agents and employees from any and all claims and liabilities resulting from participation with ACT-sponsored activities.

Parent/Guardian Signature - by filling your name, you confirm that you agree to the medical release and have the legal right to sign for medical treatment of the aforementioned minors. *

Date: *

Unless informed otherwise in writing, the Academy of Children's Theatre (ACT) considers photographs taken of students and their work in class and in performance to be permissible for publication in ACT marketing materials and in informational publications, including our website.

ACT Refund Policy:

• Cancellation 3 weeks or more before camp starts: Tuition refunded, minus a $50 admin fee.
• Cancellation less than 3 weeks before camp starts: No refund given.

I have read and understand ACT's refund policy. *

Message to ACT:

How did you hear about ACT? Please select one The Gazette - Parent's Guide CS Kids Magazine High Country Newsletter KBIQ 102.7 FM KGFT 100.7 FM Internet Search Vehicle Window Decal The Independent Friend Previous ACT Class Other

A tuition deposit is due as you register. When you click on submit, you will be directed to a payment page to make the deposit via Paypal.com, which is a secure site where you can pay by credit or debit card.

Registrations submitted without payment will NOT be reserved.

There will be a $30 fee for any bounced checks, balance transfers with insufficient funds, or credit card charge backs.