Parent/ Guardian or Caregiver Information *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Actor Information *

First Name

Last Name

Phone

(###)

###

####

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ETC Act 1

ETC Act 2

Media Release

I agree

Please do not use actor in any images/photography/video filming, and/or any reproductions or adaptations for fundraising, public awareness or other purposes.