Student's Name

First Name

Last Name

Date of Birth

YYYY

Age

Which class or classes are you interested in?

Do you have any schedule conflicts with this class/ these classes?

Contact Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Name 1

First Name

Last Name

Contact Email Address 1

Contact Phone 1

(###)

###

####

Contact Name 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Email Address 2

Contact Phone 2

(###)

###

####

Doctor's Name

First Name

Last Name

Doctor's Phone

(###)

###

####

Special Medical Info

Please include physical, social, psychological if relevant, i.e. allergies, asthma, etc.

Emergency Contact 1

In the event of an emergency, please list in order of preference the people to be contacted.

First Name

Last Name

Emergency Contact 1: Phone

(###)

###

####

Emergency Contact 2

First Name

Last Name

Emergency Contact 2: Phone

(###)

###

####

Additional Info

In the event of a medical emergency, your child will be taken to Northern Dutchess Hospital in Rhinebeck and this form will be given to the doctor on call. List below any and all information you feel important for the staff or doctor to know.

Checkbox

I authorize the Cocoon Theatre staff to follow emergency medical procedures as they feel necessary. I have read the Welcome Letter and I agree to the workshop requirements. I have made any special preferences and indications known.

Yes--sign me up!

I would prefer an in-person conversation or a phone call to discuss further!