JUNGLE BOOK KIDS ENROLLMENT FORM

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STUDENT INFORMATION

Last Name *

First Name *

Age *

Grade *

PARENT INFORMATION

Parent Name (Primary Contact) *

Parent Name (Other Parent/Guardian)

Primary Phone (XXX-XXX-XXXX) *

Phone (Home or other Parent/Guardian)

Student Phone

Email (Primary Contact) *

Email (Other Parent/Guardian)

Student Email

School

Street Address (Primary) *

Town *

Zip Code *

Street Address (Other Parent/Guardian, if different from above)

Town

Zip Code

CHOOSE A SESSION (Saturday Sold Out) *

Wednesdays, 3:00-4:30pm

EMERGENCY CONTACT INFORMATION

(OTHER THAN PARENT)

E.C. First Name *

E.C. Last Name *

E.C. Phone (XXX-XXX-XXXX) *

E.C. Relation to Child *

CLOTHING SIZES

(For costumer)

Shirt Size (Please Specify youth or adult) *

Youth Small

Youth Medium

Youth Large

Youth XLareg

Adult Small

Adult Medium

Adult Large

Adult Xlarge

Other:

Required

Pant Size/Dress Size (Please include waste & length, if applicable) *

Shoe Size *

PAYMENT INFORMATION

If paying by check, our mailing address is as follows.

23 Elephants Theatre Company
PO Box 1939
San Anselmo, CA 94979

JUNGLE BOOK KIDS enrollment fee is $440. Please select one of the following options: *

Credit Card: I would like you to email me an invoice so that I can pay online with a credit card.

Check: I'd prefer to mail in a check instead. Please include your student's name on the check's memo.

Request Financial Aid: Send me a $60 invoice to hold my spot, along with a financial aid form.

REHEARSAL CONFLICTS

Please list any conflicts that you may have with the rehearsal or performance schedule. *

MEDICAL AUTHORIZATION/PHOTO & VIDEO RELEASE

By checking this box, I hereby agree to indemnify and hold harmless 23 Elephants Theatre Company and its officers and employees from and against any and all liabilities for any injury which may be suffered by me or my child arising out of or in any way connected with participation in the program noted above. In case of an emergency, my child may be treated by a qualified physician. I give 23 Elephants Theatre Company permission to use photographs and/or videos of my child in brochures or publicity. *

I agree

Required

REFUND POLICY

If there is insufficient enrollment, the production/ class will be cancelled and your money refunded. Withdrawal from the production/class will incur a $125 fee. Withdrawal requests must be made by the first day of the production/class. THERE WILL BE NO REFUNDS AFTER THE FIRST DAY OF THE PRODUCTION/CLASS. *

I agree

Required

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