Temple Theatre Conservatory Workshops
(please use separate form for each student)

Name of Workshop_____________________________________________

Participant's Name____________________________________________

Parent/Guardian (if under 18)____________________________________

Address_____________________________________________________

            _____________________________________________________

Home Phone______________________      Work Phone________________________

Gender:  M or F
If Under 18 please complete the following

Age/Birthday  ________________________________

Emergency Contact___________________________________

Physician's Name__________________________     Phone ____________________

Health Problems/Allergies/Medications?________________________________________________
I understand that Temple Theatre will make every effort to ensure the safety of me/my child, but pledge that I will not hold Temple Theatre liable for any injury incurred while participating in the course.

____________________________________________________________________
Signature                                                                      Date
*Checks payable to Temple Theatre.  Cash/Visa/MC/Discover/American Express also accepted.  Please note that class size is limited and will be available on a first-come, first-served basis.  Each enrollment is just $150 per 5-week course and payment is due in full at the time of registration.  No refunds shall be made.  For questions, please contact Tom Dalton, Director of Education at (919) 774-4512 or educationdirector@templeshows.com