Student's Name:____________________________ Date of Birth ________________

Mailing Address: ________________________________________________________

Home Phone Number:_______________________ Parent's Work__________________

Alternate Number___________________________ Emergency Number_____________

E-mail address: _____________________________

OHIP Card #__________________________________________________________

Allergies: ____________________________________________________________

Medical Conditions: ____________________________________________________

Regular Prescriptions: __________________________________________________

I acknowledge that Rising Star Performing Arts Academy and its Director and/or instructors will not be held responsible for any accident or loss, however caused, and agree to release Rising Star Performing Arts Academy from all damages or claims which may arise as a result of such loss. I hereby give permission to Rising Star Performing Arts Academy Staff and medical personal to perform first-aid or other appropriate medical treatment to my child in my absence.

PRINT NAME ___________________________       SIGN NAME _________________________________

DATE ___________      Class: ___________________ Amount Due:__________________

________________________________________________________________________


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RISING STAR PERFORMING ARTS ACADEMY
28 Livingston Road Unit 72
Scarborough, ON
M1E 4S5