SUMMER THEATER ENRICHMENT APPLICATION A theater & performing arts program for children ages 6-11 Checks made payable to Kenan Center and sent to: 433 Locust Street, Lockport, NY 14094 ATTN: Heather Bowen Last Name Gender Male First Middle Date Age Home Telephone Female Home Address City Other Telephone State ZIP School Grade Full Name of Maternal Parent/Guardian Best Contact Phone (circle one) home /work /cell Full Name of Paternal Parent/Guardian Best Contact Phone (circle one) home /work /cell Parent Email Address Emergency Contact Phone # Relationship WEEK OF PARTICIPATION: Monday, July 27 – Friday, July 31 from 9:00 am – 1:00 pm. Each class will take place in the Taylor Theater Meeting Room and/or Taylor Theater with a performance on the evening of July 31. COST: $40.00 To be included with application. PARTICIPATION IS NOT GUARANTEED without application AND payment. *All materials are included. WAIVER I, the undersigned parent/guardian of _________________________________(child’s name), do hereby grant permission to participate in any and all of the activities of the Kenan Center’s Whimsical Sculpture Project. I agree to be legally and financially responsible, and agree to hold harmless the Kenan Center and its officers, agents and employees, from any and all claims or actions arising against or in favor of my child or myself as a result of any act by, or event, occurrence, or accident, happening to my child. I hereby give my permission for photographs and/or videos of my child to be used in promotional and website materials in connection with this program and the Kenan Center. Parent/Guardian Name (PRINT) Signature Date ACCEPTANCE There are a limited number of spaces available each week so parents are urged to apply as soon as possible. You will receive notification prior to the start of the program confirming your child’s acceptance as well as further details on schedules, classroom locations, and staff contacts.