CenterStage Homeschool Pod Registration Form

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Name *

First Name

Last Name

Address

(If different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 Phone Number *

(###)

###

####

Emergency Contact #2

First Name

Last Name

Emergency Contact #2 Phone Number

(###)

###

####

Emergency Contact #3

First Name

Last Name

Emergency Contact #3 Phone Number

(###)

###

####

In Case of Emergency *

In case of emergency do you give the staff at CenterStage Education and Consulting permission to call the ambulance or 911?

Yes, I give permission.

No, I do not.

Does Your Child Have Any Chronic Illness, Specific Medical Condition, or Food Allergies? *

Yes

No

Video and Photo Release *

I authorize CenterStage Education and Consulting to use video footage and photos of my child for promotional purposes only.

I DO NOT authorize CenterStage Education and Consuling to use video footage and photos of my child for promotional purposes only.

Signature (Please read description before signing) *

By placing your name and date below you are stating your interest in the program of your choosing and will receive an email response from infodesk@centerstageeducation.org in 24-48 hours to confirm receipt. You will be required to meet with the directors and complete further registration in person.

First Name

Last Name

Date of Signature *

MM

DD

YYYY