LTOB Youth Theatre Workshop Enrollment Form
Email *
Name and Age of child participating in the workshop (and preferred nickname if applicable): *
Name(s) of Parent(s) or Guardian(s): *
Address *
Phone number *
Emergency Contact Name and Phone Number *
Please list any accommodations your child may require to participate in our program:
MINOR PHOTO RELEASE: Little Theatre on the Bay has my permission to use my or my child’s photograph publicly to promote the theatre. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. *
MEDICAL INFORMATION: Please List Primary Care Physician’s Name and Phone Number *
MEDICAL INFORMATION: Please list Medical Insurance Provider and Policy # *
MEDICAL INFORMATION: Allergies to medications? Medical Conditions for which the minor is receiving treatment? Prescription Drugs the minor is taking? Other pertinent medical information? Please List Below *
EMERGENCY MEDICAL CONSENT: As custodian of the aforementioned minor, I grant my authorization and consent for a designated adult to administer general first aid treatment for minor injuries or illnesses. If the injury or illness is severe, I authorize him or her to seek professional emergency personnel to attend, transport, and treat the minor and to issue consent for any medical care deemed advisable by a licensed medical professional or institution. I authorize the designated adult to exercise best judgment upon the advice of medical or emergency personnel.
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TRANSPORTATION: Please specify is you have any transportation needs that would otherwise be a barrier for your child to attend this workshop. We will do our best to accommodate these needs but cannot guarantee fulfillment of all requests.
A copy of your responses will be emailed to the address you provided.
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