Registration for February Session

Thespians (5th-8th grade) 1:00-4:00pm

First & Last name of Primary Caregiver

Primary Email

Primary Phone #

Secondary Caregiver email (if applicable)

Secondary Phone # (if applicable)

Third Caregiver email (if applicable)

Third Phone # (if applicable)

Emergency Contact full name

Emergency Contact Phone #

Name of First Actor

Actor - Date of Birth

Actor -Current Grade Level

Actor's Height (in feet & inches) for costume purposes

Actor's pants size (example: Youth 10 or Women's 8 or Men's 32/34)

Name of Second Actor (if applicable)

Actor - Date of Birth

Actor -Current Grade Level

Actor's Height (in feet & inches) for costume purposes

Actor's pants size (example: Youth 10 or Women's 8 or Men's 32/34)

Does your actor have any allergies or health concerns that our education staff should be aware of?

Does your actor have any communication, mobility, or other needs that you would like us to know about?

Anything else you would like for us to know about your actor?

RELEASE AUTHORIZATION

For Publicity, Medical Emergency, Liability Waiver, and Medical Release

By agreeing and submitting this form I signify that I, or the performer(s) for whom I am the legal guardian, agree to participate in this Midcoast Youth Theater (MYT) production, including rehearsal and performances.

I hereby release MYT, its partners and all employees, agents, officers, and volunteers from liability claims, demands or suits for property damage and personal injury which could arise out of the course of participating in this program. I understand that these activities may involve physical exercise and perhaps a health risk and I will release all above-mentioned parties from any claims.

I also grant permission for emergency medical attention in case I am not able to be reached. Medical issues such as allergies, diagnoses, or behavior concerns, as latex allergies, ADHD, or anxiety in large groups can be communicated to the Director to help ensure everyone has a positive and safe experience. This information will not affect casting decisions but will help the production team and/or MYT board members prevent, plan, and respond to everyone’s needs. This information will be kept confidential and only shared with those who are part of the production team and/or MYT Board.

I understand that Midcoast Youth Theater may photograph or videotape rehearsals or performances for archival or publicity purposes. These images may be published or broadcast in news coverage, media events or on the Internet.

Signature

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