Minor Details - Model & Talent Registration

Personal Information

First Name:*	Last Name: *

Date of Birth: Month * Day * Year *	S. I. N. #: (Optional)

Mother's Name:	Mother's Work Number:

Father's Name:	Father's Work Number:

Address:*

City:*	Province: *

Postal Code:*

Home Phone:* (000) 000-0000	Cell Phone:

Pager:	Fax:

Email: *

Passport: If yes, expiry date: MM/DD/YYYY

Citizenship:*	Union:

Please select what applies to you

Good Hands:		Are you interested in hand modelling? (If yes, please submit a photo of your hands.)

Contact Lenses:		Glasses:

Ears Pierced:		Tattoos:

Allergies:
Animals:	Penicillin:	Peanut:	Dairy:	Pollen:	Bees:	Other:

Activities /Team Sports

Activities/Solo

Sports/Solo

Leisure/Solo

Dance Modern:	Dance Ballet:	Dance Jazz/Tap/Acrobatic:

Dance Ballroom/Salsa:	Instrument Keyboard:	Instrument Wind:

Instrument Strings:	Instrument Guitar:	Instrument Percussion:

Yoga/Tai Chi:	Cheerleading:	Fitness Weights/ Aerobics:

Brownies/ Sparks/ Girl Guides/ Pathfinder/ Scouts/ Cubs:

Circus Balance-Tightrope/Unicycle/Stilts:

Sing:

Attach your image

PLEASE NOTE:
You have the option to submit 3 images, but you must submit at least one image. Acceptable image types: jpg, jpeg, png, gif Acceptable max image size: 800Kb If you have difficulty submitting your image(s), please send your files to minordetails@rogers.com to add to your profile.

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Experience

Please list all school plays / Community Theatre & other acting related experience including the year(s):
(maximum length 650 characters)