REGISTRATION

Performer
Gender:  
Performer First Name:   Performer Last Name:    DOB:       
Address:  
City:   State/Region:   Zip/Postal Code:    
Email Address:
*all correspondence for the event will be sent to this email address    Phone:  
Studio:   Teacher:  
Location and Package
Location:  
Package Selection:  
Qualified at:  
Referred By:
Add on Packages
Will the participant be performing in the Improv Showcase? ($30.00 charge)

 
Would you like to add the NEXT STEP Package? ($75.00 charge)

 
Apparel Size
Street Shoe Size:    
T-Shirt Size    
Hotel or Commuter Package
 
Spectators
* Every Performer is required to attend Power Pak with a registered spectator. If you are not registering a spectator,
please indicate which registered spectator you will be traveling with:  
Package Summary
Item Description Price Quantity Amount
Total Amount Due: .00
Scholarships & Discounts
Scholarship:
Payment
 
Emergency Contact
* All fields in this section are required

Parent/Guardian
Name:  
Work Phone:  
Cell Phone:  

Alternate Contact
Name:  
Relationship:  
Work Phone:  
Cell Phone:  

Family Physician
Name:  
Phone:  
Dismissal Info (Optional)
Please complete the following dismissal release information if you know an adult over 21 years of age who is registered as a Power Pak spectator that you would like to give permission for your child to go with during Power Pak free times. Performers will only be released to their parent or guardian if this section of the form is not completed. Power Pak reserves the right to revoke permission if there is any violation of the Power Pak rules set forth for the tour.

I hereby grant permission for the spectator(s) listed below, who are a part of the Power Pak tour, to pick up/drop off and supervise my child during Power Pak free times. I understand that the spectators must be a part of the Power Pak tour and must be over 21 years of age.
Spectator #1: #2: #3: #4:
Parent/Guardian Signature:
Senior Dismissal Info (Optional):
This section must be completed if your child is 12 or older, traveling with their parent or guardian, and wishes to have permission to be dismissed from Power Pak activities without a parent or guardian present. If this section is not complete, Performers will not be dismissed until a parent, guardian or spectator listed above is present at dismissal.

I hereby grant my permission for my child to be dismissed without a parent, guardian or spectator present. I understand that Power Pak reserves the right to request a Spectator be present at dismissal from specific activities if they feel necessary.

Parent/Guardian Authorization:
Signature Authorization

I,   , Parent or Guardian of the performer listed above, have read the following Power Pak Documents:

Power Pak Documents and Policies

By clicking the submit button below I acknowledge that I understand and agree to all of the terms stated
in the above listed Power Pak Documents.

*** ATTENTION: Clicking the submit button multiple times could result in multiple charges! ***