Young & Teen Scene Study Pre-Registration

Last Name: First Name: Middle Initial:

Permanent Address:

City: Province: Postal Code:

D.O.B.: (m)(d)(yr)     Grade:

Home Tel: Cell/Pager:

Work: Email:

Medical & Allergy Alert - Please list any medical or allergy information that we should know:

Mother's Name: Email:

Home Tel: Business Tel:

Father's Name: Email:

Home Tel: Business Tel:  

Have you previously taken an A.C.T. course? Yes / No

Why do you want to take this course?

Please provide a brief summary of any relevant acting experience or training:

ACT Permission & Photo Permission

I give permission for to attend A.C.T. classes. In consideration of A.C.T. accepting the above mentioned minor as a participant of Acting in front of the Camera, we and each of us for ourselves and our heirs do voluntarily waive and release each and every right or claim for damages we and each of us have or may have against the school, its agents or representatives for any and all injuries or mishaps howsoever occasioned.

I give permission for the use of photographs that may be taken during the workshop or other activities related to A.C.T. to be used by A.C.T. in brochures or for advertising and promotion for the school.  I understand that there will be no financial remuneration for the use of any photograph.

Name of Parent/Guardian:

Date:

Please check which course you will be taking:

YOUNG & TEEN SCENE STUDY, SUNDAYS - January 24-March 14 (2:00pm-5:00pm)

Unless otherwise notified, the workshop will take place at Arts Court, 2 Daly Avenue, Ottawa, ON (between Waller and Nicholas Streets, across from the Novotel Hotel and the Rideau Centre)

Payment Options

AEarly Bird (must pay by December 29) -
I will send a current cheque in the amount of $367.50 ($350.00 + 5% GST)

BAfter December 29, I will send a current cheque in the amount of $393.75 ($375.00 + GST)

CAttached, please find my signed registration form and 3 Cheques.  A current cheque of $100.00 (to reserve my spot), together with my cheques of $150.00 (dated no later than January 19) and $143.75 or $117.50(ACTRA/CAEA members) dated no later than February 19, 2009.

DI am paying online using Paypal.

Before you click the SUBMIT button below, please print this page and mail a copy with your cheque(s) payable to: A.C.T.

Send your printed copy and cheque(s) to: