CenterStage Microschool Enrollment Form

1st Enrollment

Reenrollment

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 signing this form, you confirm your decision to enroll your child in CenterStage Education & Consulting's Microschool Program. You will receive a confirmation email within 24-48 hours. Please note that the $40 enrollment fee is non-refundable.

First Name

Last Name

Date of Signature *

MM

DD

YYYY