Winter Registration Form - Trollwood Performing Arts School

TROLLWOOD WINTER REGISTRATION FORM 2016
Mail, email or fax completed registration form and payment to Trollwood Performing Arts School.
Mail: 801 50th Ave S, Moorhead, MN 56560 | Email: [email protected] | Fax: 218-477-6501
If you have any questions please call 218-477-6500.
Please print clearly:
Note any conflicts with session schedule:__________________________
Student Name __________________________________________________
Date of Birth (M/D/Y)____________________ Male
Female
Current Age____________________________________________________
Current Grade___________________________________________________
Current School__________________________________________________
Student Address_________________________________________________
______________________________________________________________
Emergency contact (must speak English):
Name__________________________________________________________
Relationship____________________________________________________
Evening & Weekend Phone (very important!)__________________________
Medical Information:
City, State, Zip___________________________________________________
Please note medical problem/allergies or special needs Trollwood should
Student Home Phone_____________________________________________
be aware of (this information is confidential):_________________________
Student Cell Phone_______________________________________________
______________________________________________________________
Student E-mail Address___________________________________________
Living with (check one):
Mother
Father
Both
Other
Please note your preferred health care provider (only to be used in case of
emergency):____________________________________________________
Please turn over for payment and class registration >>>
Circle Relationship and Print Name:
Mother/Stepmother/Guardian_____________________________________
Address (if different than above)____________________________________
Employer_______________________________________________________
Work Phone_______________________ Home Phone__________________
Cell Phone______________________________________________________
E-mail Address__________________________________________________
Circle Relationship and Print Name:
Father/Stepfather/Guardian_______________________________________
Address (if different than above)____________________________________
Employer_______________________________________________________
Work Phone_______________________ Home Phone__________________
Cell Phone______________________________________________________
E-mail Address__________________________________________________
Check the one category that best describes your predominant racial/
ethnic identity:
Caucasian (white)
Asian or Pacific Islander
Hispanic or Latino
Black or African American
Native American or Alaskan Native
Middle Eastern or Arab American
Other__________________
Parent/Guardian or student (18 or older): please read, check one & sign below:
Consent is granted to Trollwood for the use of media images involving my
child/myself for publicity and marketing purposes for the organization.
I agree to the above Media Release Statement
I do not agree to the above Media Release Statement
Signature______________________________________________________
Date _________________________________________________________
At Bluestem Center for the Arts
TROLLWOOD WINTER REGISTRATION FORM 2016
Mail, email or fax completed registration form and payment to Trollwood Performing Arts School.
Mail: 801 50th Ave S, Moorhead, MN 56560 | Email: [email protected] | Fax: 218-477-6501
If you have any questions please call 218-477-6500.
Check Desired Session:
Trollwood Winter Academy
Current High School Students Grades 9 - 12 & College Students
Musical Theatre Dance & Voice Intensive: An Audition Prep Class
Jan. 10, 17, 24 & Feb. 7, 14, 21 | 2:00pm-4:45pm
Lucile’s Dance Studio | Trollwood
$150 for 6 class session | Registration Deadline: Jan. 6
Instructors: David Triptow & Ryan Domres
Sound Recording Basics
Jan. 10, 17, 24 & Feb. 7, 14, 21 | 2:00pm-3:30pm
Recording Studio | Trollwood
$90 for 6 class session | Registration Deadline: Jan. 6
Instructor: Michael Beatrez
Payment Total:
Musical Theatre Dance & Voice Intensive ($150) $____________
Sound Recording Basics ($90)
$____________
Total Fee $______________
Payment Enclosed $______________
Balance Due $______________
Payment Options (please check one):
Fee payment in FULL with completed form
OR
Half down w/registration and balance due Jan. 9 (credit card required)
Payment Method (please check one):
Cash
Check or Money Order | Payable to Trollwood
Visa
MasterCard
Discover
Card #___________________________________________________
Exp. date______________CVV# (3 digit # on back of card)_______________
Signature________________________________________________
Date____________________________________________________