OR, call to register by phone using a MasterCard or VISA! (616) 455-1001 or 1-800-455-5003

Student Name:___________________________________________________________

Sex     M     F                         Age _____                 Birth Date:____/____/____

Entering grade _____     (Entering third grade minimum requirement)

School  _______________________________________________________

Parent or Guardian's name(s):__________________________________________

Home phone: (______)_______________    Daytime phone: (______)_______________

Address:__________________________________________

City, state, Zip: __________________________________________

Enclosed is my check for $________________, payable to Master Arts Theatre. I hereby release, absolve, indemnify and hold harmless the Master Arts Theatre directors and staff members; and in case of injury during normal routines and activities outlined above, I hereby waive all claims against the above. I assume all risk incidental to the conduct of these activities and transportation to and from Master Arts activities. In case of injury during camp hours call:

_______________________ at (_____)_______________ (ph#)

and/or our family physician:

Parent or Guardian Signature: __________________________________   Date: ________