Student Registration and Medical Form

Layout

Student's Name

First

Last

Student's Address

Address Line 1

Address Line 2

City

State

Zip Code

Student's Date of Birth

Student's Gender

Student's Email

Student's Phone

Layout

Parent's/Guardian's Name

First

Last

Is Parent's/Guardian's Address same as Student's Address above?

Yes
No

Parent's/Guardian's Phone

Parent's/Guardian's Email

Preferred method to contact Parent/Guardian for non-emergencies

Email
Phone - Voice Call
Phone - SMS/Text Message

Emergency Contact

Layout

Emergency Contact Person

First

Last

Relation of Emergency Contact Person

e.g. mother, father, uncle, friend

Emergency Contact's Phone

Student Health Information

Layout

Student's Allergies, Medical Conditions, Medications Taken

e.g. peanut allergy, asthma, epilepsy, etc. For medications, please include why and when your child needs to take the medication. If none, specify "None".

Student's Additional Physical or Emotional Support Conditions

e.g. Wheelchair accessibility, Autism, ASD, ADHD. If none or choose to not provide, specify "None".

Student's Special Dietary Conditions

If none, specify "None".

Is there anything else you want to inform us regarding health or medicine?

Agreement

By signing, I agree to the holding of this information and understand Dallas Film School will not pass information onto third parties without prior permission. The information I have provided is correct as of the date signed. I hereby release The Dallas TV & Film Workshop (D.B.A. Young Actors Studio) and Dallas Film School from any liability regarding my child (named student above). I fully understand my rights and give the employees of The Dallas TV & Film Workshop and Dallas Film School permission to administer or call upon emergency assistance if an employee of The Dallas TV & Film Workshop or Dallas Film School deems it necessary. I understand this release is effective starting the date signed through December 31, 2024.

Parent/Guardian Signed

Please sign above.

Date