Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

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Photography Waiver *

By checking this box, the parent permits Miss Tilly's Ballet & Theater Arts to record photographs or video of your child as a program participant. You grant the Miss Tilly's Ballet & Theater Arts all rights to use these sound, still or moving images in any medium for educational, promotional, advertising or other purposes that support the mission of the Miss Tilly's Ballet & Theater Arts. All rights to the photographs or video belong to the Miss Tilly's Ballet & Theater Arts.