BLT Student Information Name ___________________________________  Age ________ Parent’s Name(s) _____________________________________ Mailing Address _____________________________________                 ______________________________________ e-mail address _________________________ (print or write clearly) Home Phone _______________  Cell Phone _______________ Alernate Phone ______________________ Emergency Contact #1 __________________________________ Phone # __________________________ Emergency Contact #2 __________________________________ Phone #___________________________ DISCLAIMER:   Although I know that every effort is made to insure the safety and well-being of my child, I will not hold Brevard Little Theatre or its representatives responsible for bodily injuries or property damages that may occur to _____________________ before, during or after youth theater classes.                                                                         Signed____________________________                                                                                                            Date _____________________________ ----------------------------------------------------------------------------------------------------------         (for office use only) Amount due ___________________ (Theater Arts classes) Amount due ___________________ (Dance classes) Amount paid ___________________