Libertyville IP Elite: Anything Goes
1st Rehearsal: April 5, 2017
Tech Week/Performances: May 15-20th
(13 Week Term)
This group rehearses: Wednesdays: 7:00 pm-9:00 pm
Sundays: 3:30 pm-5:30 pm
Student's Name (First, Last):
Parent/Guardian Name: (*If Guardian, please include your relationship to student): (First, Last)
Parent/Guardian's Primary Phone Number:
Parent/Guardian's Secondary Phone Number:
Emergency Contact Name (First, last):
Emergency Contact Relationship to Student:
Emergency Contact's Primary Phone Number:
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:
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
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.
Discounts: (Check all that apply)
Sibling Discount? Registering for 2 family members: $10 off
Multiple Class Discount? (Registering for more than one class per term: $10 off)
Multiple Class Discount? (Registering for consecutive sessions: $10 off)
Scholarships: (Need-based scholarships are available on a first-come, first-serve basis. Please inquire about payment plans.)
Payment: (this class costs $395 per term)
Credit (4% Processing Fee will be charged)
Credit Information (only if paying with credit) *Please note that this form is not encrypted. You can call to give this information after registering if you do not feel comfortable sharing online. Must call with in 1 business day with information.
Credit Card Number:
On behalf of the Improv Playhouse Staff, thank you for involving your student in The Arts. We hope you have a wonderful session. See you soon! - IP STAFF
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