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2015 LORAIN PALACE YOUTH THEATER
STUDENT REGISTRATION FORM
DATE_____________________
STUDENT’S NAME___________________________________________
PHONE (_____)______________________
ADDRESS_______________________________________ CITY____________________ STATE____ ZIP___________
BIRTH DATE ______________ AGE (as of 6/21/13) _________ SCHOOL GRADE (entering in fall 2013) ____________
HEIGHT ______ (INCHES)
WEIGHT _____ (LBS.) HEALTH CONCERNS: ___________________________________
(LIST ANY WE SHOULD BE AWARE OF)
MOTHER’S NAME: _______________________________ FATHER’S NAME: _________________________________
MOTHER’S ADDRESS: _____________________________________________
PHONE: (_____)_______________
(If different from student) FATHER’S ADDRESS: ______________________________________________ PHONE: (_____)_______________
(If different from student)
MOTHER’S E-MAIL: _______________________________
FATHER’S E-MAIL: ____________________________
EMERGENCY CONTACT: ____________________________________________ PHONE: (_____)_______________
(if parent is unreachable)
LIST PREVIOUS THEATER TRAINING EXPERIENCE: ____________________________________________________
LIST PREVIOUS DANCE EXPERIENCE: _______________________________________________________________
MUSICAL INSTRUMENTS PLAYED: __________________________________________________________________
PLEASE LIST ANY DATES YOU ARE AWARE OF THAT YOU WILL MISS DUE TO VACATION, ETC: ____________
_________________________________________________________________________________________________
TUITION FEES:
$300.00 PER STUDENT Until June 11, 2015 $350 After June12, 2015
NO REFUNDS (AGES 8 TO 18 by June 8, 2015)
ENCLOSE CHECK OR MONEY ORDER PAYABLE TO: Lorain Palace Theater
VISA or MC ACCOUNT # _____________________________________ EXP. DATE ____________
MAIL TO:
THE LORAIN PALACE THEATER
PYT 2015
617 BROADWAY
LORAIN, OH 44052
PRIORITY REGISTRATION DEADLINE: June 11, 2014 - 3:00 PM; OTHERS PENDING AVAILABILITY
OFFICE USE ONLY:
TUITION PAID $_____________ DATE_____________ CHECK NO./CASH________________ RECEIVED BY:
____________________________________ CREDIT CARD APPROVAL # ______________________
2015 SUMMER YOUTH THEATER WORKSHOP STUDENT
WAIVER RELEASE & INDEMNIFICATION FORM
LORAIN PALACE THEATER
STUDENT’S NAME:
_____________________________________________________________
(PLEASE PRINT)
In consideration of permission to enter the premises of the Lorain Palace Theater, and
further consideration of permission to participate as a paid student at the Lorain Palace
Theater, I, parent or guardian, of the above named student, being of lawful age, for myself,
my heirs, administrators, executors, successors and assigns hereby fully and forever
release, acquit and discharge the Lorain Civic Center Committee, Inc., together with its
successors and assigns, its members, its trustees, its officers, its employees and/or agents
from any and all actions, causes of action, claims and demands of whatsoever kind or
nature arising out of the above students activities during his/her participation of the 2015
Summer Youth Theater Workshop at the Lorain Palace Theater.
Furthermore, I hereby agree to indemnify the Lorain Civic Center Committee, Inc., its
successors and assigns as well as its members, trustees, officers, employees and agents
from and against all liabilities, judgments, decrees, fines, penalties, expenses, fees,
amounts paid in settlement or any other costs, losses, expenses (including, but not limited
to attorney's fees and court costs) arising or resulting from or in connection or association
with the workshop activities as a student at the Lorain Palace Theater.
PARENT/GUARDIAN:
__________________________________________________________
WITNESSED BY: ______________________________________________________________
DATE: _______________________
2015 PYT T-Shirt Order
Form Lorain Palace Youth
Theater.
A t-shirt will be created for this year’s production.
ALL REGISTERED STUDENTS RECEIVE A
T-SHIRT AS PART OF THEIR
ENROLLMENT FEE.
IF YOU WOULD LIKE TO PURCHASE AN ADDITIONAL T-SHIRT, PLEASE
MAKE A NOTE OF THE SIZE & QUANTITY BELOW THE NAME LINE.
Please complete this form to be sure that your son or
daughter receives this lasting memento of their 2015 PYT
experience. THANKS!
FORM MUST BE TURNED IN WITH PARENT PACKET BY JUNE 4th, 2015
STUDENT
NAME:________________________________________________________
YOUTH SIZES:
_____ Medium (10-12)
_____ Large (14-16)
ADULT SIZES:
_____ Small (32-34)
(40-42)
_____ Medium (36-38)
_____ Large
_____ Extra-Large (44-46)
_____ Double Extra-Large (48-50)
(52-54)
_____ Triple Extra-Large