UCA Upper Canada Academy of Performing Arts

Program_______________________

Name________________________Birthday_________________________

Allergies, Medical Conditions?___________________Health Card #___________________

Parent/Guardian __________________________________________

Phone :Home#______________ Work #____________Cell :_______________

Mailing Address :________________________________Postal Code:______________

E Mail address___________________________________________

Emergency Contacts: (2)_____________________________________(phone #)__________________

Do we have your permission to use photographs taken to help promote the

Upper Canada Academy of Performing Arts? __Yes __No

I understand that there are risks involved in any activity or program and I acknowledge that my

choice to participate or register my child/self at the Upper Canada Academy of Performing Arts brings with it the

assumption of those risks. I am aware of no physical or other reason why the named student

should not participate in this program. I do hereby release the Upper Canada Academy of Performing Arts, its employees, Board members, and agents, including any facility or location where this program is held from fault for injuries due to participation in this program.

Parent/Guardian Signature: Date:

I hereby give permission for my child/ward ________________________________to participate

in the classes, events and performances of the Upper Canada Academy of Performing Arts.

Parent/Guardian Signature: Date:_______________________

Paid : Fee____cheque_________ cash________

Where did you hear about UCA? ______________________

Have fun!

Please mail with cheque payable to

Upper Canada Academy of Performing Arts 

108 Albert St 

Kingston k7L3V2

Ontario

Canada