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7th - 12th Graders
IP Blackbox Theatre - 735 N Milwaukee Ave, Libertyville, IL 60048
Student's Name (First, Last):
Parent/Guardian (First, Last) (*if guardian, please include your relationship):
Parent's/Guardian's Primary Phone Number:
Parent Guardian's Secondary Phone Number:
Emergency Contact Name:
Emergency contact Relationship to Student:
Emergency Contact's Secondary Phone Number:
Please list all student allergies and necessary medical supplies i.e. EPI-Pen etc. (even minor allergies, better safe than sorry!):
Please list any/all medical information or behavioral health information for your student:
Please provide your mailing address below:
Any other questions or concerns you would like to make the IP Staff aware of? Please let us know! We are happy to read and help answer any necessary questions/concerns/comments.
Photo Release Permission:
I, the undersigned parent/guardian, grant permission to The Improv Playhouse Theater and its staff, administrators, and parent volunteers to use my child's name and image in any publicity. I understand that publicity may include both print and electronic means for the purpose of informing the community of events, program advertisement, production sales and distribution, or other promotional publicity. This includes, but is not limited to newspapers, brochures, show posters, The Improv Playhouse website, The Improv Playhouse Facebook page, and The Improv Playhouse Constant Contact emails.In checking the box marked "YES - I DO grant permission" I am giving my written consent to release my child’s name and image to The Improv Playhouse for the aforementioned promotional purposes.
YES - I DO grant permission
NO - I DO NOT grant permission
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