Student Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Contact Information *

First Name

Last Name

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone *

(###)

###

####

Emergency Contact Information *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Primary Physician *

First Name

Last Name

Health Insurance Provider Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Health Insurance Provider Phone *

(###)

###

####

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Yes

No

Is your child allergic to any type of food or medication?

Yes

No

Does your child require a special diet?

Yes

No

In case of medical emergency contact: (If different from contact above)

First Name

Last Name

Medical emergency contact: Phone

(###)

###

####

How did you hear about The Wallace Theater. *

Website School

Word of Mouth

Flyer Other