215 Live Entertainment Registration Form Student Name * First Name Last Name Parent Name First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Cell Number * (###) ### #### Email * Date of Birth * MM DD YYYY Current Age * Grade in School Gender * Emergency Contact 1 Name First Name Last Name Emergency Contact 1 Phone * (###) ### #### Emergency Contact 2 Name First Name Last Name Emergency Contact 2 Phone (###) ### #### Any Health, Allergies, and/or Physical conditions (injuries, medications etc) we should be aware of: * Select Company * Acting Dance Both Please write a short paragraph about why you would like to become a member of 215 Live Entertainment Company * Signature (Print Name) * Date MM DD YYYY Thank you for registering with 215 Live Entertainment!
