Parent/ Guardian or Caregiver Information * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Actor Information * First Name Last Name Phone (###) ### #### Please list any medical concerns or allergies * Select your class ETC Act 1 ETC Act 2 Media Release I agree Please do not use actor in any images/photography/video filming, and/or any reproductions or adaptations for fundraising, public awareness or other purposes. Thank you!