Acting Class Registration

PRINT THIS FORM AND SEND WITH FEE TO THE ADDRESS AT THE BOTTOM

Name: ________________________________________________________________

Address: ______________________________________________________________

STREET CITY ZIP

Phone: ____________________ E-mail Address: ____________________________

Class and Day: _________________________________________________________

Parents: I look forward to providing your child with an exciting, fun, and safe class experience.

We do not participate in any dangerous physical activities. However, in the event of an emergency, please provide me with the following information:

Parents’ Names: _________________________________________________________

Phone Numbers: HOME)______________ WORK)_____________ CELL)________________

Emergency Contact (other than parent): _______________________________________

Phone: _______________________________________________

Insurance Company: _________________________________________________

Policy Number: ___________________ Student’s health concerns or allergies (food,

drugs, etc.): _____________________________________________________________

If parents or emergency contact cannot be reached, I authorize Helen Kearney Konen to seek medical assistance for my child. I agree to hold Helen Kearney Konen and Theatre Charlotte harmless for personal illness or injury.

My child agrees to exercise care in the facility and I agree to reimburse Theatre Charlotte for any personal breakage, damage or loss of property due to his/her negligence.

________________________________________________ ____________________

Parent/Guardian Signature Date

TO REGISTER:

Please send a non-refundable deposit of $75 (applied to tuition) to secure seat in class.
Make check payable to: Helen Kearney Konen and return to: 2936 Saintfield Place

Charlotte NC 28270

704-540-7781

Helen Kearney Konen has a B.A. in Theatre Arts from California State University Long Beach. In California, she was trained in the Actor's Studio Method by Mathias Reitz, an early actor in Lee Strasberg's famed Actor's Studio in New York. She has acted and directed for over thirty years. She teaches adult classes at Myers Park Baptist Church and children's classes at Theatre Charlotte. She also conducts acting workshops and is a private coach. Her actors have won numerous awards in the Talent Inc. Conventions in the Southeast.

Setting the Stage

With Helen Kearney Konen