Child First Name*
Child Last Name*
Birth Month*
Birth Date*
Birth Year*
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:*