Our Lady of the Lake

Parent/Guardian information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Contact Phone*

Child Information

Child's Name*

First Last

Age*

Date of Birth*

Grade in School*

Does your child have any allergies?*

If you answered Yes, please list them below*

What is the name of your child's teacher?*

What is your child's room #?*

Is there anything else we should know about your child?

How did you hear about us?

Emergency Contact

Name*

First Last

Email

Phone*

Relationship to child*

Alternate Adult Authorized to pick up Child

Name

First Last

Phone

Payment Method*

Credit Card*

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Release Form

I hereby give permission to Wedgwood Drama Studio to photograph and video my child while involved in class activities and performance and I hereby give authorization to Wedgwood Drama Studio to use such photographs for ALL promotional use - website, brochures and/or other publicity purposes.

Permission*

Class Registration amount*

Price: $130.00

Cancellation Policy: Your payment includes a $40 non-refundable registration fee. You must cancel two weeks before class begins to receive a refund minus the $40 registration fee. If you cancel with less than two weeks’ notice, no refund will be given. If after attending the first day you decide the class is not the right fit, please let us know before the second class and we will refund your tuition minus the registration fee. Cancellation by WDS: If enrollment for the class is insufficient, we reserve the right to cancel the class. In this case, tuition including the registration fee will be refunded in full.

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Parent/Guardian information

Child Information

Emergency Contact

Alternate Adult Authorized to pick up Child

Release Form