School Break 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 *

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

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? *