A or B A or B A or B TOTAL $ BRING completed form with payment
2015 CHILDREN’S SUMMER WORKSHOP REGISTRATION FORM CIRCLE PREFERRED Workshop Workshop A July 20 – Aug 1 Workshop B Aug 3 – 15 (Brief audition 7/19) (Brief audition 8/2) Workshop space is limited and will be filled on a first-come, first-served basis. Name Gender School Date of Birth M F / / M F / / M F / / Grade T-shirt Size (in Fall 2015) YM AS YM AS YM AS YL(10-12) YXL AM AL AXL YL(10-12) YXL AM AL AXL YL(10-12) YXL AM AL AXL Circle Preferred Workshop Fee A or B $ 275 A or B $ 225 A or B $ 225 TOTAL $ MAIN HOUSEHOLD CONTACT (please print) Name E-mail__ ________ Street Address ________________________________________________________________ City Home Phone (___________)____________--____________________ EMERGENCY MEDICAL INFORMATION EMERGENCY CONTACT State _____ Zip Mobile Phone (___________)____________--____________________ Participant’s Doctor Phone: (______)_______- Participant’s Dentist Phone: (______)_______Relationship Phone: (______)_______- List any health problems, medications, allergies or special needs or circumstances: LIABILITY WAIVER FOR PARTICIPANT/GUARDIAN: In consideration of your accepting my or my child’s entry, I hereby, for myself, my child, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I or my child may have against the Aurora Community Theatre, its representatives, successors and assigns for any and all injuries suffered by myself or my child on any activity sponsored by these groups. I do hereby grant the right for my child(ren) to be photographed at Aurora Community Theatre for purposes of publicity and promotion including press releases and ACT-produced newsletters, brochures and all printed materials, as well as video and audio recording. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the Aurora Community Theatre harmless of and from any and all liability of whatever nature which may arise out of or result from such uses. For the consideration stated above, I further agree that in the event that my child repudiates or attempts to repudiate such release, I will personally indemnify and save harmless the Aurora Community Theatre, its successors and assigns, for any and all loss and damage occasioned hereby. Parent/Guardian Signature: Date: _____/_____/_______ BRING completed form with payment to OPEN REGISTRATION April 30, 2015 between 6 and 8 pm Make checks payable to Aurora Community Theatre OR Visa MC Disc Amex ________________________________________________________exp ___________ cvv________ Signature____________________________________ After April 30: Mail to Aurora Community Theatre PO Box 9 Aurora, Ohio 44202 No refunds will be given after June 1, 2015 FOR OFFICE USE ONLY: PMD____________#___________ CK #________________________ CK AMT ____________________ CK Date____________________
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