PUSH Physical Theatre Summer Intensive Registration Form
June 18th - July 1st, 2017
PUSH Physical Theatre
389 Gregory St. Unit 400
Rochester, NY 14620
USA
Contact us at: chitchat@pustheatre.org
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Name
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Address
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Phone
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Date of birth
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Gender
First week only or both weeks?
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Education level (school grade/college/higher education/etc.)
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Arts training background and/or experience
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How did you hear about us?
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Consent/Medical Release
You are eligible to participate in a the PUSH Physical Theatre Summer Intensive 2017. A two-week physical theatre intensive that requires vigorous exercise in Rochester, NY. Beginning Sunday, Jun 18th 2017 and ending Saturday, Jul 1st 2017.

To participate in this event, please complete the following statement of consent and release of liability.

I understand that...
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Emergency contact name and relationship to you
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Emergency contact phone
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List any allergies or medical, physical, or dietary restrictions/requirements:
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List any medications you are presently taking (including over-the-counter medications):
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Medical insurance company
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Insurance policy ID number
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Payment
In order for my registration to be completed...
I understand that my remaining balance is due no later than June 1st, 2017:
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My remaining balance (due June 1st) is:
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