Child First Name*

Child Last Name*

Birth Month*

Birth Date*

Birth Year*

Gender

Height

Grade

Mailing Street*

Mailing City*

Mailing State/Province*

Mailing Zip/Postal Code*

Primary Guardian Email*

Have you participated in Palace Youth Theatre Programs in the past?

If yes, please list up to 5:

Guardian Name/s*

Home Phone*

Guardian Email 1*

Guardian Phone 1*

Guardian Email 2

Guardian Phone 2

Primary Emergency Contact Name*

Primary Emergency Contact Phone*

Please list any and all Medical Conditions that apply: (if none, please type N/A)*

Additional Medical Information

Please list any and all allergies that may apply:*

List any daily medications with useful information, instructions, and activity restrictions: (if none, please type N/A)*

Please initial and date to confirm that you have read and agreed with the Photo Release Form, Liability Waiver and Safety/Behavioral Guidelines:*