Acting Class Form

Acting Class Form

Please fill out the form below and we will contact you soon.
Student's Name*

First NameLast Name
Gender
School
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Parent Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any ADA accommodations needed
Tell us about yourself
Specify any of your child's health problem's
Is your child on any medication? if so, please specify:

Parent Information
Dad's Name

First NameLast Name
Dad's Cell Phone
Please enter a valid phone number.
Dad's Work Phone
Please enter a valid phone number.
Mom's Name

First NameLast Name
Mom's Work Number
Please enter a valid phone number.
Mom's Cell Phone
Please enter a valid phone number.
Person Authorized for Pick-Up*

First NameLast Name
Other Dismissal Arrangements*
Emergency Contact*
Please list Name, Relationship, and Phone number

REQUIRES PARENT'S SIGNATURE:
MEDIA RELEASE
I hereby give permission to LilyRoze Inc., to photograph and/or videotape the student for educational or promotional purposes. Initial*
PARENT STATEMENT

I hereby state that Camper's name * is in good mental and physical health condition to participate in the activities provided by LilyRoze Inc., including but not limited to
all aspects of cheerleading, tumbling, and dance training, baseball,
basketball, soccer and or competition. I am fully aware that any activity
involving motion, height or athletic activity creates the possibility of
serious injury. I hereby release LilyRoze Inc., its employee and its staff
from liability to the above named camper, of the person claiming through
him/her, arising from injury to the person or property of the above named
camper occurring in the premises of LilyRoze Inc., including any event
sponsored or sanctioned by LilyRoze Inc., and or travel to and from such
activities.

I understand that LilyRoze Inc., has the right to deny admittance to any
student not meeting the standards of the program as it sees fit. I also agree
not to hold these parties responsible in the event that my son/daughter/child
engages in inappropriate conduct (including, but not limited to disruptive or
volatile behavior in or out of camp, etc.) or becomes involved in any activity
or with any persons not associated with LilyRoze Inc., or its scheduled
program and that LilyRoze Inc., has the right to send him/her home for
inappropriate conduct. I further attest that the information contained in
this application is correct to the best of my knowledge. In addition, I have
agreed to the policy and fee statement and agree to comply.
Parent/ Legal Guardian Signature*

Clear
You have our permission, in the event of an emergency and in case we are unavailable, to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my childblanks* as they may deem advisable
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Signature*

Clear
Student's Allergies*
Student's Medical Problems*
Doctor blanks* Phone Number blank* fields and text.
Insurance carrierblanks Policy numberblank
Who is financially responsible for the student? *

If you want to pay with Debit, Credit, or PayPal (Skip this section) - If you select an option from the drop down below, click the submit button at the bottom of this application. An invoice will be sent once we receive this application
Please select option below:*

Registration Fee: $50.00 (intensive)Registration Fee: $50.00 (fall break)Intensives $295.00Camps $85.00 Per Week
Select Experience Level:

Beginner‎Intermediate‎Advanced

My Products

Class Registration Fee

$50.00

Total

$0.00

Credit Card

We do not provide make-ups or refunds for any days missed for any reason. Please do your best to come to each session.
Parent/Legal Guardian

First NameLast Name
Parent/Legal Guardian

Clear
Should be Empty:

Acting Class Form

Parent Information

REQUIRES PARENT'S SIGNATURE:

Credit Card