980 American Pacific Dr #103 Henderson, NV 89014

Kris Blake -- Owner /Director -- 702-286-7242

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Registration Information

Please complete the following information before your child attends any classes at Seedling Theatre Company. Items marked with an * are required information.

Student First and Last Name

Child lives with:

Both parents

Mother only

Father only

Joint custody

CONTACT Parent or Legal Guardian full name

Best Contact Email

Best Contact Phone

current age of child

Child's Date of Birth

Child's identifying gender

Female

Male

Additional Parent/Guardian full name

Additional Parent/Guardian Email

Additional parent/guardian Phone

Does your child have any medical conditions (physical, mental, emotional) that might limit participation in activities?

Yes

Does your child have any allergies?

Yes

Is your child currently taking any prescription medications?

Yes

If you answered yes to any question, please provide additional details

Any other information you think we should know about your child?

1) Name of additional individual authorized to pickup my child:

Contact's Phone

2) Name of additional individual authorized to pickup my child:

Contact's Phone

3) Name of additional individual authorized to pickup my child:

Contact's Phone

4) Name of additional individual authorized to pickup my child:

Contact's Phone

Seedling Theatre Company, L.L.C. has my permission to use my child’s photograph or image to publicly to promote the company and its programs. I understand that the images may be used in print and online publications, presentations, website and social media. I also understand that no royalty, fee or other compensation shall become payable to me or my child by reason of such use.

Yes, I agree

No, I do not give permission for my child's image to appear in any print or online promotional materials for Seedling Theatre Company, LLC. I understand that this excludes my child from any Movie Making classes or camps.

I approve ONLY the inclusion of my child's image in licensed video recordings of end-of-semester performances.

By checking this box, I declare that the info I’ve provided is accurate & complete.

By checking this box, I declare that I have read and understand the Seedling Payment and Attendance Policy View policy

By checking this box, I declare that I have read and discussed with my child the Seedling Code of Conduct and agree to abide by its terms. View Code of Conduct

By checking this box, I declare that I have read and discussed with my child the Seedling Safety Policy and agree to abide by its terms. View Safety Policy

Your Signature

Thanks for submitting!

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Questions or Requests:

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