PERFORMING ARTS DISTANCE LEARNING LAB

ENROLLMENT FORM

Student Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Email

Student Phone

(###)

###

####

Date of Birth

Age

Sex

Male

Female

Grade Level 20/21 School Season

Are you registered in Virtual Learning through your school?

Yes

Name of School

Known Allergies

Any Health Concerns or Physical Restrictions?

Known Learning Challenges

Are immunizations up to date?

Do you have a working laptop or iPad to bring to class?

Yes

Parent Name

First Name

Last Name

Parent Email

Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Session

Please Select Sessions you are interested in

If you chose 1- 3 weeks of enrollment which weeks are you interested in?

Notes/Questions/Concerns?