FVCT Workshop Registration Form
Please complete this form to enroll your child in the Disney: Stage & Screen Workshop with Michael Berkeley & Heather Holohan-Guarnieri. Tuition is $500; a non-refundable deposit of $50 and this registration form will confirm your child's enrollment in the workshop, with the remainder of tuition due on the first day of the workshop. (Program is subject to minimum enrollment.)

Please pay by check made payable to "FVCT" and mail to: Pamela Chassin, 369 Wells Hill Rd., Lakeville CT 06039.

DISNEY STAGE & SCREEN: 3 Weeks, 10 am–3 pm, Mon–Fri, July 31–August 19, 2017
Performances Dates: Friday Aug. 18 at 7 pm, Saturday Aug. 19 at 2 pm & 7 pm
$5 per ticket; each students will receive two (2) complimentary tickets

Student Name
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Nickname
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Date of Birth
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Grade
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School
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T-Shirt Size
Parent/Guardian Name
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Address
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Home Phone
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Work Phone
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Cell Phone
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Additional Phone Numbers
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Parent Email 1
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Parent Email 2
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Summer Address if different
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Summer Phone if different
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Name and relationship of contact in case of emergency when parent/guardian cannot be reached:
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Phone 1 of Emergency Contact:
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Phone 2 of Emergency Contact:
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Please list any allergies, medical conditions, or other important information we should know about your child.
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Child's Physician
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Physician's Phone
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Your name printed below serves as your signature granting the following Medical Emergency Release: Medical Emergency Release: I authorize the Falls Village Children’s Theater Company to administer care and treatment for injuries and/or illnesses for my child that may occur while in session. I authorize the release of information and medical records to facilitate the medical, surgical or psychiatric care of my child. In the event of an emergency, illness or injury in which a delay may jeopardize the life of the recovery of my child and I am unable to be contacted, I authorize the Falls Village Children’s Theater Company and/or its representatives, instructors, volunteers or staff to assume responsibility for the care and treatment of my child which many include hospitalization, diagnostic tests and/or surgery.
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Your name printed below serves as your signature giving approval for this Participation Release: I/We, the parent(s) of the above named child(ren), hereby give approval for him/her/them to participate in any and all activities of the Falls Village Children's Theater Company and do hereby waive, release, absolve, indemnify and agree to hold harmless the Falls Village Children's Theater Company, all organizations, all organizers, all instructors, volunteers, officers, directors, sponsors, supervisors, participants and persons involved in the Falls Village Children's Theater Company, for any claims arising out of any injury, including transportation to and from activities, to my/our child(ren) whether the result of negligence or for any other cause. This release holds true for my child(ren) as well and myself/ourselves.
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Your name printed below serves as your signature and grants permission for your child’s photo to be taken and used, possibly, to publicize other FVCT theatre camps, classes and workshops. In addition, your signature gives permission for the FVCT to videotape rehearsals and performances, when allowed.
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Your name printed below serves as a signature agreeing with the following: The Falls Village Children’s Theater Company reserves the right to dismiss students for behavioral issues. Our instructors strive to insure a fun and educational experience for all of our students. A dismissal due to behavioral issues is highly unlikely. Your signature below serves as acceptance of this policy.
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