Acting Lessons

Student First Name *

Student Last Name *

Student Cell Phone *

Student Email Address - Please do not enter parent/guardian email address here. *

Gender: How does student identify? *

Male

Female

Non-Binary

Prefer To Self-Describe (please use space below)

Prefer to Self-Describe:

Which pronouns does student prefer? *

Student Date of Birth * +

Home Address *

City *

State *

Zip Code *

How did you hear about acting coaching with Broadway Training Intensive?
(Please be specific.) *

If student is under 18, the following must be completed for at least one parent/step-parent/guardian. (Optional but encouraged for students who are between 18-21.)

Parent / Step-Parent / Guardian 1 - FIRST NAME

Parent / Step-Parent / Guardian 1 - LAST NAME

Parent / Step-Parent / Guardian 1 - Email Address

Parent / Step-Parent / Guardian 1 - CELL PHONE

Parent / Step-Parent / Guardian 2 - FIRST NAME

Parent / Step-Parent / Guardian 2 - LAST NAME

Parent / Step-Parent / Guardian 2 - Email Address

Parent / Step-Parent / Guardian 2 - CELL PHONE

Emergency Contact - NAME
(Please do not list parents/guardians you've already included above. In the case of an emergency, we will attempt to contact the above parents/guardians first, and if we are unable to reach them we will contact this person.) *

Emergency Contact - RELATION *

Emergency Contact - CELL PHONE *

Is there anything we should know about the student’s health?
For example, asthma, allergies (including food and medication), injuries, or surgeries?

If not applicable, please type "None" in the box. *

Are there any other medical or psychiatric conditions we should be aware of?
If so, please explain.

If not applicable, please type "None" in the box. *