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. _________________________
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