subject_line
One Day Holiday Camp Registration
Student First Name:
*
Student Last Name:
*
Student's DOB (XX/XX/XXXX):
*
Student Gender
*
Male
Female
Non-Binary
School
PARENT #1 INFORMATION
Parent # 1 First Name
*
Parent # 1 Last Name
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Parent # 1 Home Phone
Parent # 1 Work Phone
Parent # 1 Cell Phone
Student's Cell Phone
Parent # 1 Email Address*** This email will be considered the "primary" address and will receive all communications from kidsActing
*
PARENT #2 INFORMATION
Parent #2 First Name
Parent #2 Last Name
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Parent #2 Home Phone
Parent #2 Work Phone
Parent #2 Cell Phone
Parent #2 Email Address
Student's Cell Phone
Student's Email Address
ADDITIONAL PICK UP PERSON(S)
Unless indicated here, only Parent 1 and Parent 2 will be able to pick this student up from camp. Please use this section to list any additional people who have permission to pick up this student.
Additional Pick Up Person 1
Additional Pick Up Person 2
Additional Pick Up Person 3
EMERGENCY CONTACT
(Other than Parent)
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Home Phone
Emergency Contact Cell Phone
Does your child have any allergies or physical restrictions we need to know about?
I hereby grant permission for kidsActing to use my child's likeness (in photos) for future publications, social media, and/or photo galleries on our website.
*
Yes
No
How did you hear about kidsActing?
*
My child is already a student
An email I received
Online
Brochure in mail
Friend
A kidsActing employee
Facebook
Instagram
Peachjar Email
School
Event
Anytime Fitness
Austin American Statesman
Austin Chronicle
Kids Directory
Austin Family
Community Impact
Other