Participant Information:
Last Name: _________________________ First Name: _________________________ Date of Birth: ____________________
Health Card #: _________________________ Address/Unit #: ___________________________________________________
City/Town: _____________________________ Province: ___________________ Postal Code: ________________________
Name of Parent/Guardian: ______________________ Telephone: __________________ Alt. Telephone: _______________
Primary E-mail: _____________________________________________________ (Most information is distributed via E-mail.)
T-Shirt Size: ___________ (Circle: YOUTH or ADULT)
 Male  Female
Age (in July 2015) __________
How did you hear about our Young Company Program?
 Brochure  Other ____________________________
Emergency Contact Information:
Main Emergency Contact: ______________________________ Relationship to Participant: __________________________
Main Emergency Telephone: ____________________________
Alternate Emergency Contact: ___________________________ Relationship to Participant: __________________________
Alternate Emergency Telephone: _________________________
Special Needs or Medical Information: _____________________________________________________________________
_____________________________________________________________________
Please Note: A signed note from a Doctor or Guardian must accompany any medication brought by a Participant to the Bruce County Playhouse
Young Company.
Session Information:
I would like to enroll my Participant in the following Bruce County Playhouse Program for 2015:
 Bruce County Playhouse Young Company Production of Cinderella for Ages 9 – 16 (Aug. 4 – Aug. 29)……………….$720.00
Payment Information:
Complete this form and mail/attach payment to:
Bruce County Playhouse 323 Gingrich Cres., Port Elgin, ON N0H 2C1 Attn: Young Company
Payment Options:
 Full Payment ($720.00)  Monthly Post-dated Cheques (To: Bruce County Playhouse) divided into equal amounts until Registration Deadline
If you have any questions regarding our payment options or program, please email us at [email protected].
Participant Release Form: I agree that, having taken such precautions as in your discretion are deemed advisable, that Bruce County Playhouse and/or the Bruce
County Playhouse Young Company Summer Program, including staff, will not be held responsible for any sickness and/or accident to the Participant, no matter how
caused. If for any other reason the Participant requires medical attention, I agree to be responsible for any and all expense incurred. I covenant and agree to indemnify
Bruce County Playhouse, its employees and staff and save them harmless from and with respect to all suits, actions and claims by reason of any activity carried out by the
Participant, whether on or off the Saugeen District High School’s property.
Due to limited cast size, no place can be held without receipt of the ENTIRE ENROLLMENT FEE. The enrollment fee will be returned if the Bruce County Playhouse Young
Company Summer Program is full and the applicant cannot be admitted. My signature also gives Bruce County Playhouse permission to use any 2015 Bruce County
Playhouse Young Company Summer Program photos and/or writings for future BCP Young Company marketing and/or promotional purposes, which may include, but are
not limited to, use on a website and/or within publications.
REFUND POLICY: Requests for refund of the enrollment fee must be made 30 days prior to the first day of my selected BCP Young Company Summer Program session. NO
ENROLLMENT FEE REFUNDS WILL BE MADE AFTER THIS TIME. A $40.00 administration fee will be subtracted from the total of my refund; please allow 10 business days to
process the refund. During the session, there is no refund for illness, missed days, vacation, withdrawal, or if the Participant is dismissed by the BCP Young Company staff.
Dismissals: Any Participant whose behavior is deemed inappropriate by the BCP Young Company staff will be given one warning, which will include a notification to their
guardian. Should the inappropriate behaviour continue following this warning, the Participant will be dismissed from the program with no refund.
The Bruce County Playhouse Young Company is an equal opportunity organization. Participants will be admitted regardless of race, ancestry, place or origin, colour, ethnic
origin, citizenship, creed, sex, sexual orientation, disability, gender identity or gender expression. Bruce County Playhouse regrets that the facilities used are not
wheelchair accessible.
Information is collected under the Privacy Act and may be used for purposes of administering the BCP Young Company Summer Program, including communicating with
the parent/guardian regarding issues related to the BCP Young Company Participant. I, the undersigned, have read and fully support this Participant Release Form.
Signature of Parent/Guardian (age 18 and over): ___________________________________________________________
Date: _______________________________ Printed Name of Guardian: ________________________________________