Kid's Summer Workshop - Registration & Medical Form

IMPORTANT: All registrants MUST pay for the camp through the ticket portal following submission of the registration form to complete the process and receive your receipt/confirmation.

Kid's Theatre Workshop - Registration & Medical Information

Please note all fields with a * are required. Make sure to fill in all required fields BEFORE you click the SUBMIT button at the bottom, or you may need to fill in the entire form again.

* Indicates required field

Participant's Name *

First

Last

Age *

Grade in School (Coming year) *

T-Shirt Size *

Parent/Guardian's Name *

First

Last

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Email *

Street Address *

City *

State *

Zip Code *

For Emergency Notify: *

First

Last

Relationship *

Emergency Contact Phone Number *

Alternate Emergency Phone Number *

PARTICIPANT'S EMERGENCY MEDICAL INFORMATION

Doctor's Name *

First

Last

Doctor's Phone Number *

Pharmacist *

Pharmacist Phone Number *

Does the participant take any prescription medications regularly? *

Yes No

Currently Taken Medications *

Does the participant have known allergies? *

Yes No

List any allergies *

Does the participant have any known life-threatening physical problems? *

Yes No

List any known life-threatening physical problems: *

AGREEMENT *

I understand that this information will be used by Brownwood's Lyric Theatre for the purposes of registering the listed participant in the Kid's Summer Workshop. I understand and agree to release the information contained on this form to Brownwood's Lyric Theatre for the purposes of registration and to ensure proper care of the listed participant and I have submitted all necessary medical and emergency care and contact information for the participant to the best of my knowledge.

PLEASE NOTE: Registration information will also need to be signed on the first day of the workshop.

Submit