Registration Form & Medical Release

Name__________________________________________________________________________

Age________________Grade______________DOB__________________________________Gender: M F

Address_____________________________________________________________________________________

City________________________________________State____________________________Zip_____________

Telephone__________________________Cell Phone___________________________________Text: Yes No

Mothers Name______________________________Fathers Name____________________________________

Email_______________________________________________________________________________________

Emergency Contacts (with phone numbers) _______________________________________________________

_____________________________________________________________________________________________
Tuition
Little Ones (Ages 4-8) Go FishUnder the Sea ThemeJune 26-30, 20179 am-12 noon
Teen (Ages 12-19) Making the BandRock & Roll Garage Band ThemeJuly 10-14, 2017
9 am-12 noon with luncheon theater on Friday, July 14, at 12:30 pm
Junior (Ages 8-12) JoustMedieval Theme (Knights, Princesses, & Dragons)July 31-August 4,
20179am-12 noon

Tuition: $100.00 (No refund) Paid_____________Cash____________Check____________

Make Checks Payable to Shenandoah Youth Musical Theater Date Paid_____________

Medical Release & Waiver

Any known allergies or other medical concerns____________________________________________________

_____________________________________________________________________________________________

I hereby authorize the agents of Shenandoah Youth Musical Theater to act for me according to his/her best judgment in
any emergency requiring medical attention for my child. Every effort will be made to contact me before any medical
decision is made. I hereby release and discharge Shenandoah Youth Musical Theater and its staff from and against any
and all liability or causes of actions arising out of or in connection with my or my childs participation in the program.

Parent Signature_________________________________________________Date_________________________

Please call 540-477-2511 or 540-333-2727 with any questions. Mail completed form with payment to
Shenandoah Youth Musical Theater c/o Kathy Rinard, 5880 Main Street, Mt. Jackson, VA 22842.
Remember to make checks payable to Shenandoah Youth Musical Theater.