Adult Professionals Pre-Registration

Last Name: First Name: Middle Initial:

Permanent Address:

City: Province: Postal Code:

D.O.B.: (m)(d)(yr)     Age:

Home Tel: Cell/Pager:

Work: Email:

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

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

In consideration of A.C.T. accepting me, , in the course noted below, I and my 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 promotional material for the school.  I understand that there will be no financial remuneration for the use of any photograph.

Name: Date:

Please check which course you would like to take:

Adult Professionals  (18 & up) - A) SUNDAYS - March 6 to May 1, 2011 (11:00-2:00)
                                                          or B) THURSDAYS - March 3 to April 24, 2011 (6:30-9:30)

 Note: Please email your preference to actottawa@rogers.com

Payment Options:

A I will send a current cheque in the amount of $423.75 ($375.00 + HST)

BI will send a current cheque in the amount of $100.00 (non-refundable deposit) to reserve my spot, a cheque of $150.00 (dated no later than March 3), together with my cheque in the balance of $173.75 (dated no later than April 3).

CI am paying online using Paypal or via INTERAC EMAIL MONEY
transfer to actottawa@rogers.com

Unless otherwise notified, the workshop will take place at 111A Rideau Street
(Third Floor, Studio Three)

Before you click the SUBMIT, please insure that all information is accurate.

Send your cheque(s) to: