Additional information
Child's Information
First Name:Required
Last Name:Required
Nickname or Preferred Name (if different):
Pronouns (for ex. He/Him/His; She/Her/Hers; They/Them/Theirs):
Date of Birth:Required
Name of School: (if applicable)
Grade for 2026-2027 School Year (Current Grade):Required Please Select Grade Preschool Grade Pre-K Grade K Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
How are you (the purchaser) related to the student?Required Please Select Parent Step-Parent Grandparent Uncle/Aunt Family Friend Other
Parent/Guardian Information First Name: NameRequired
Address:Required
City:
CountryRequired Please Select Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azores Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Botswana Brazil British Virgin Islnd Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cameroon Canada Canal Zone Canary Islands Cape Verde Cayman Islands Central African Rep Chad Channel Islands Chile Colombia Comoros Confed of Senegambia Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czechoslovakia Dahomey Denmark Djibouti Dm People's Rp Korea Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Estonia Ethiopia Faeroe Islands Falkland Islands Fed Rep of Germany Fiji Finland France French Guiana French Polynesia Gabon Germany Ghana Gibraltar Gilbert & Ellice Is Greece Greenland Grenada Guadaloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle Of Man Israel Italy Ivory Coast Jamaica Japan Jordan Kampuchea Kenya Kiribati Kuwait Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Mali Malta Martinique Mauritania Mauritius Mexico Monaco Mongolia Montserrat Island Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles Nevis New Caledonia New Guinea New Hebrides New Zealand Nicaragua Niger Nigeria Niue Northern Ireland, UK Norway Okinawa Oman Pacific Islands Pakistan Panama Papua New Guinea Paraguay People's Dm Rp Yemen People's Rp of China Peru Philippines Pitcairn Poland Portugal Portuguese Guinea Qatar Republic of Korea Republic of Maldives Reunion Islands Romania Russia Rwanda Ryukyu Islands Saint Lucia San Marino Sao Tome & Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St Martin St Vincent & Grenad St. Kitts and Nevis Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tanzania Thailand The Bahamas The Gambia Tibet Timor Togo Tonga Trinidad & Tobago Tunisia Turkey Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Unknown Upper Volta Uruguay USA Vanuatu Vatican City Venezuela Vietnam Wales Western Samoa Yemen Arab Republic Yugoslavia Zaire Zambia Zimbabwe
State/Prov: Please Select Aberdeenshire Alabama Alaska Alberta American Embassy American Embassy American Samoa Angus Argyll Arizona Arkansas Armed Forces Australian Antarctic Territory Australian Capital Territory Avon Ayrshire Banffshire Bedfordshire Berkshire Berwickshire British Columbia Buckinghamshire Caithness California Cambridgeshire Channel Islands Cheshire Clackmannanshire Cleveland Clwyd Colorado Connecticut Cornwall County Antrim County Armagh County Down County Durham County Fermanagh County Londonderry County Tyrone Cumbria D.C. Delaware Derbyshire Devon Dorset Dumfriesshire Dunbartonshire Dyfed East Lothian East Sussex East Yorkshire Essex Fife Florida Georgia Gloucestershire Guam Gwent Gwynedd Hampshire Hawaii Herefordshire Hertfordshire Idaho Illinois Indiana Inverness-Shire Iowa Isle Of Lewis Isle Of Skye Isle Of Wight Kansas Kent Kentucky Kincardineshire Kirkcudbrightshire Labrador Lanarkshire Lancashire Leicestershire Lincolnshire Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Merseyside Michigan Micronesia Mid Glamorgan Middlesex Midlothian Minnesota Mississippi Missouri Montana Morayshire N/A Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New South Wales New York Newfoundland Norfolk North Carolina North Dakota North Humberside North Lincolnshire North Yorkshire Northamptonshire Northern Mariana Is. Northern Territory Northumberland Northwest Territory Nottinghamshire Nova Scotia Ohio Oklahoma Ontario Oregon Orkney Oxfordshire Palau Peeblesshire Pennsylvania Perthshire Powys Prince Edward Island Puerto Rico Quebec Queensland Renfrewshire Rhode Island Ross-Shire Roxburghshire Rutland Saskatchewan Select State Selkirkshire Shropshire Somerset South Australia South Carolina South Dakota South Glamorgan South Humberside South Yorkshire Staffordshire Stirlingshire Suffolk Surrey Sutherland Tasmania Tennessee Texas Trust Territories Tyne And Wear Utah Vermont Victoria Virgin Islands Virginia Warwickshire Washington West Glamorgan West Lothian West Midlands West Sussex West Virginia West Yorkshire Western Australia Wigtownshire Wiltshire Wisconsin Worcestershire Wyoming Yorkshire Yukon
Postal Code:
Relationship to Student:Required Please Select Parent Step-Parent Grandparent Guardian Other
Primary Phone Number:Required
Primary Email for all class communication:Required
Second Parent/Guardian Information Name:
Second guardian's Phone Number:
Second guardian's email address:
Relationship to Student: Please Select Parent Step-Parent Grandparent Guardian Other
Does the Second Guardian reside at the same address as the Primary Guardian? Please Select Yes No
Additional Emergency Contact Information
Additional Emergency Contact Name:
Emergency Contact Phone:
Relationship to Student: Please Select Parent Step-Parent Grandparent Uncle/Aunt Family Friend Other
If your child has SEVERE allergies that we should be aware of, please list them below. If you plan to leave an Epipen during class times, please indicate below.
Does the student regularly take any medications that we should know about? If yes, please list below. If no, please write 'none'.
In order to best serve each student, please list all physical, psychiatric, cognitive, medical, emotional, learning needs, behavioral challenges, other special needs, or anything else you would like us to know. This information is invaluable to providing a positive experience. Indicate any activities that have been discouraged or limited by participant's physician. Please help us serve your child by being specific:
How did you hear about this class?: Please Select Previous Class Round House Theatre Website From a Friend Round House Theatre Brochure at School Round House Theatre Email Camp Fair Other
REFUND POLICY:
I understand a full refund will be made when a program is cancelled due to insufficient enrollment. A full refund, minus a $25 processing fee is available if the participant is withdrawn at least 30 days prior to the start date of the program. A 50% refund is available if withdrawing less than one month but more than two weeks prior to a program's start date. No refunds will be made within two weeks of program's scheduled start date and/or after a program has begun.
Yes I understand and accept the Refund PolicyRequired
MEDICAL WAIVER:
In the event of an emergency, I give my permission to Round House Theatre to secure and administer treatment, including hospitalization, for the participant as named on this form.
Round House cannot administer over-the-counter or prescription drugs to my child unless that medicine is sent in a properly labeled container provided by the pharmacy and accompanied by a medical authorization form.
Round House assumes no liability for injuries or damages arising from participation in any class or program. Due to the strenuous nature of some activities, the participant is encouraged to consult a physician concerning fitness to participate.
Yes I understand and accept the Medical WaiverRequired
MEDIA RELEASE:
I understand that by completing this form Round House Theatre has my permission to use the image of participant as named on this form in publicity about Round House Theatre. If I do not wish Round House to use image of participant for publicity, I understand I must contact Education@RoundHouseTheatre.org to make this request.
Yes I understand and accept the Media ReleaseRequired
ADDITIONAL POLICIES
Rules and guidelines are intended for the safety and protection of all children and staff. Please review our Participant Code of Conduct with your student. If negative behavior persists, RHT will consult with parent/guardian. If a student is unable to correct behavior which is dangerous or disruptive to the program, suspension or dismissal from the program may occur.
Yes I understand and accept the additional Round House PoliciesRequired
