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Student Info Form

*Student's First Name:

*Student's Last Name:

*Student's School:

Please select an option from the drop down menu.

Student's Grade Level:

*Student's Age:

*Birthdate:

*Address Line 1:

Address Line 2:

*City:

*State/Province:

*ZIP/Postal Code:

*Parent's Name(s):

Parent's Name(s):

*Parent's Email 1:

Parent's Email 2:

*Parent's Phone Number 1:

Parent's Phone Number 2:

Please list any allergies or physical limitations your son/daughter has:

Is there anything Act Up! should know in order to offer your son/daughter the best experience possible?:

*I hearby grant permission to Act Up!, its instructors, and/or affiliates to take photographs of myself or my child(ren) during the course of their time with Act Up! without further recourse. I understand that such photographs may be used for future promotional and/or commercial purposes.:

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