DRAMA REGISTRATION FORM - Mail to: Roberta Woolfson.        360 Federal Hill Rd, Milford NH 03055

                                                                        (Include check for $170 made out  to Town of Hollis)  

Hollis Drama Program

 

Student's Name: __________________________________________________________

 

Address: ________________________________________________________________

 

________________________________________________________________

 

Date of Birth:__________________ Age: _______________ School Grade: __________

 

      I am registering for the      3:30 to 5 PM ___   5:00 to 6:30 PM ___  program

 

Does participant have any health disorders, medication, or emotional limitations we should know about? 􀂆

Please add details on separate sheet if needed.

 

In case of injury, medical authorities will not undertake any medical treatment without parental/guardian consent. This form allows for such medical care should you not be available to give permission. It will be kept by the teacher in case of emergency.

I agree to have my daughter/son treated for emergency medical and/or dental problems that should result from injuries received provide a licensed physician or dentist advises such treatment. I accept full responsibility for the cost of the treatment.

I WILL NOT HOLD ROBERTA WOOLFSON, LIGHTSUP DRAMA or THE TOWN OF HOLLIS RESPONIBLE FOR ANY INJURY OR COST.

 

 

Parent/Guardian Name: ___________________________________________________________________ (Please PRINT name)

 

 

Parent/Guardian Signature: ____________________________________________ Date: ______________

 

 

Home Phone: _______________ Cell Phone: _____________ Email _____________________________

 

 

Health Insurance Provider: ________________________ I.D./Group No. _________________________

 

www.lightsupdrama.com