Intensive Acting with Claudia Jurt
 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

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:

   AINTENSIVE ACTING
2) Mondays - September 20-November 8, 2010

Please list all the days of the week that you are available for, in order of preference.  We will do what we can to accommodate, but there are no guarantees.

Cost: $385.00 + 13% HST = $435.05 Early Bird Discount: $359.00 + 13% HST = $405.67 (must pay by Septembe 13)                                 ACTRA/CAEA Members:  $359.00 + 13% HST = $405.67 PRE-REQUISITE(S): By Invitation Only      AUDITING COSTS:   $20.00/class (+ 13% HST) = $22.60 $125.00/8 classes (+ 13% HST) = $141.25   To be considered for this class as a participant or auditor, please email your photo/resume to actottawa@rogers.com and answer the following questions: 1. Why do you like to act? 2. Why do you want to study in this classroom? All NEW applicants MUST send a photo & answers to above questions to actottawa@rogers.com before their applications will be considered.

Unless otherwise notified, the workshop will take place at 1724 Bank Street, Ottawa, ON (between Waller and Nicholas Streets, across from the Novotel Hotel and the Rideau Centre)

Payment Options

AEarly Bird Discount (must pay by September 13)
Attached, please find my signed registration form and my cheque
of $405.67 (incl. HST) in full payment.

BAfter Early Bird Deadline - Attached please find my signed registration form and my
cheque of $435.05 (incl. HST) in full payment.

CAttached, please find my signed registration form and 2 Cheques.  A current cheque of $150.00 (to reserve my spot), together with my cheque of $285.05 or $255.67 (ACTRA/CAEA Members) dated no later than September 20, 2010.

DAUDITING ONLY - Attached please find my signed registration form and my cheque of $141.25 (incl. HST) in full payment.

EI 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: