Which workshops or courses would your child like to attend?
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Check all that apply.
Adult's First and Last Name:
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First Name
Last Name
Adult's Phone:
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(###)
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Adult's Email:
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Additional Adult Name
First Name
Last Name
Additional Adult Phone in case of Emergency:
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(###)
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Current Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's First and Last Name(s):
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First Name
Last Name
Child's Nick Name (Optional):
Child's Date of Birth
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MM
DD
YYYY
Child's Pronouns:
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Child's Grade:
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Please list any of the child's allergies/dietary restrictions/medications:
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What is the primary language spoken at home?
What else should we know to make sure your child has a good time?
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How did you hear about this program?
Is there anything else you'd like us to know about your circumstances?
I authorize the Children's Museum & Theatre of Maine to use my child's appearance/photograph in publicity materials:
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