Name of Student________________________________ Age _______ Date of Birth ___________
If Student is a Minor:
     Grade _________ Parent/Guardian Name____________________________________________

Home Phone  ___________________________

Home Address_______________________________________________________________________

Cell Phone: Student _________________AND/OR Parent ________________________________

Email: Student  ________________________AND/OR Parent ______________________________

Emergency Contact_________________________________________________________________  

Class Preference______________________________________________________________________

Health Conditions_____________________________________________________________________

Wexford Acting Studio Medical Release Form:
I do hereby release the Acting Studio and all instructors from any and all claims for damages or for
injuries which I, or the minor student may sustain while participating in any activities with the Acting
Studio. I do also give the Acting Studio permission to obtain or provide any necessary medical
attention for the student.

________________________________________________________Date_________________
Signature of Adult Student, Parent or Guardian

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Tuition (Office Use Only)
Sep_____Oct_____Nov_____Dec_____Jan_____ Feb_____Mar_____Apr_____May_____Jun_____
Registration Fee _____