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***** Each student must be registered separately *****
Chris' Upstage Performance Studio must receive a $25 Registration Fee (one per family)
and Tuition Fee to validate online registration.
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Student Last Name
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Student First Name
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M.I.
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Street Address
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Apt #
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P.O. Box
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City
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State
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Zip Code
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Student Birth Month
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Day
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Birth Year
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Gender
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Phone Number
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Class Selection
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Day
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Hour
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Minute
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AM / PM
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1st
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2nd
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3rd
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4th
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5th
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I have read and understand the Memberships. Therefore,
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I will allow a doctor's treatment to myself/my child in an emergency?
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1. Emergency Contact Name
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1. ER Home Phone
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1. ER Work Phone
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1. ER Cell Phone
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2. Emergency Contact Name
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2. ER Home Phone
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2. ER Work Phone
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2. ER Cell Phone
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3. Emergency Contact Name
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3. ER Home Phone
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3. ER Work Phone
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3. ER Cell Phone
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Health Issues / Allergies / Medications
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Physician Name
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Address
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Phone Number
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Hospital Name
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Address
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Phone Number
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Parent/Guardian First Name
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Parent/Guardian Last Name
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Email
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I certify that I am at least 18 years of age and/or the legal parent/guardian of the
student named above.
A Registration and Tuition Fee in the form of a check/money order or online payment
must be received by Chris' Upstage Performance Studio to validate this registration.
I know that I should make a copy of this information for my records.
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