Cincinnati Black Theatre Company
Cincinnati Black Theatre Company
Saturday Performing Arts Classes
Click here for Printable Form

Today's Date:   mm/dd/yyyy 
  Last Name:    First Name:     MI: 

  Grade:      School Name:    Birth Date:  

     Age:               Sex:        Male     Female:

 Please check below which area interests your child the most       
      Dance          Vocals          Set Design           Drama

Parents Name:    Cell Phone:    Home Phone: 

Street Address:    City:   State:    ZipCode:  

Email Address: 

Occupation:   Employer:  

Employer Phone Number: 

 Name of local friend or relative:    Relationship to Camper:   
(not living at the same address)

Home Phone:    Work Phone: 

Wavier for Participation and/ By Parent:  In consideration of your accepting me or child's entry, I am hereby for myself, my heirs, executors, and administrators, wavier and release any rights and claim for damages I or my child may have against the Cincinnati Black Theatre company and its representative, successors and assigns for any injuries suffered by myself or my child on any activity sponsored by said group. 

  Check here to indicate that you have read and agree to the provisions in the wavier and initial below

Your Initials: 



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