Libertyville A.C.T.: The Nerd
7th-12th Graders
Role Assessment: March 21st, 2017
Tech & Dress Rehearsals: Tues 5/16, Th 3/18, & Tue 5/23 7:30 - 9:30pm
Performances: Th 5/25 8:00pm, Sat 5/27 3:00pm and Sun 5/28 3:00pm
(12 Week Term)
Rehearsing Tuesdays and Thursdays 7:30pm- 9:30 pm
Libertyville Blackbox
New Student?
Student Name (First, Last):
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Student's Age:
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Parent/Guardian Name: (*If Guardian, please include your relationship to student): (First, Last)
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Parent Guardian's Primary Phone Number:
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Parent/Guardian's Secondary Phone Number:
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Parent/Guardian E-mail:
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Emergency Contact (First, Last)
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Emergency Contact Relationship to Student:
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Emergency Contact Primary Phone Number:
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Emergency Contract Secondary Phone Number:
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Please list all student allergies and necessary medical supplies i.e. EPI-Pen etc. (even minor allergies, better safe than sorry!):
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Please list any/all medical information or behavioral health information for your student:
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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.
Please provide your mailing address below:
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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!:
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Discounts: (Check all that apply)
Scholarships: (Need-based scholarships are available on a first-come, first-serve basis. Please inquire about payment plans.)
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Payment: (this class costs $340 per term)
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.
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Credit Card Number:
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IMS/AOB#:
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EXP:
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SEC Code:
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Electronic Signature:
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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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