Registration Form

ALGONQUIN THEATRE Drama For Kids

APPLICATION FORM

FAMILY INFORMATION PLEASE PRINT NEATLY

Participant’s NAME
Date of Birth Day/Month/Year
Parent/Guardian’s NAME						RELATIONSHIP

HOME PHONE #		WORK/DAYTIME PHONE #					CELL PHONE #

Address				Town				Postal Code
Email Address

EMERGENCY INFORMATION PLEASE PRINT NEATLY

EMERGENCY CONTACT NAME

PERMISSION TO PICK UP

YES

NO

HOME PHONE #

WORK/DAYTIME PHONE #

RELATIONSHIP

REGISTRATION

Registration 2 Registration 1

DATES – Mondays		Time		Price
Fairytale Fans 5 – 7 yrs		5-5.45 pm		$110.00
Musical Mayhem 8 – 12 yrs		6.00 – 7.15		$130.00
Total

Registration Fees and Additional Notes

Dates	Mondays: September 20 to November 29 excluding October 11 - Thanksgiving
Performance	At the end of the 8 week session a performance will be held (date TBD) and each participate receives two (2) complementary tickets. Additional tickets $5.00 each.
Non-Resident Fee	A 10% non-resident fee will be applicable to each non-resident registration.
Photos	Throughout the sessions, photos will be taken for publications. Please indicate YES or NO if it is ok for your child’s photo to be taken.	YES	NO	Parent/Guardian Initial
Participant’s Code of Conduct	Participants and Parents are required to understand and sign. Please return signed form by the first day of instruction .	YES	NO	Date Returned

PAYMENT OFFICE USE

Amount Paid

Method of Payment

Please circle

CASH VISA MASTERCARD

Received By

Date Received