Libertyville Junior High Improv Ensemble - Term 1
Grades  4th-7th
Instructor approval, referral or audition: Sunday August 21st 3:00pm

SUNDAYS 3:00-4:30 pm
Term 1: August 28th-October 30th

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Grade (Fall) *
Student Name *
Parent/Guardian Contact 1 *
Phone number (cell) *
Phone number (home)
Phone number (work)
Parent/Guardian (Contact 2) *
Phone number (cell) *
Phone number (home)
Phone number (work)
Student's Doctor's Name and Number
Medical Conditions Staff should be aware of
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