Students Last Name:

Date of Birth:

Age:

Address:

City/State/Zip:

Parent Name(s):

Home Phone:

Cell Phone:

*Email Address:

Paypal email (if different from above):

Please register me for the following class(s):
**Class Title:

Time/Day/Fee:

**Class Title:

Time/Day/Fee:

**Class Title:

Time/Day/Fee:

**Total of Payment sending to Paypal:

Additional Contact in Case of Emergency:

Any Known Allergies:

Any Know Medical Conditions or Chronic Ailments:

Medications Currently Taking:

In the event I am unable to pick up my child, I give permission for my child to be released to the following person(s)...(please provide Name and Phone #'s):

May we administer Tylenol to your child if requested?
Yes
No

Please read and sign the following waiver and release:
I agree to release and discharge StarLight Productions and its officers, directors and agents of, and from, any claims, demands, or liability of damage arising from the participation of my child in any classes and programs sponsered by StarLight Productions.

Agreement to waiver and release:
Yes, I Agree

Your Intials serve as a Signature.
Enter Initials as Signature:

**Registration Code: (if applicable)

Comments:

**By Clicking Submit, you will be directed to Pay Now by using our Paypal page.

**Paypal charges a convenience fee per transaction. These fees will appear as "shipping and handling" Thank you!