Lighthouse Players WINTER 2020: MATILDA Class
Winter Session: January - March 2020
Class Location: Madison Middle School
Contact us at: admin@lighthouseplayers.org especially if it is requiring permission. Thank you for your patience.
Email address *
Student Name *
Your answer
Age / Grade *
Your answer
Birthdate
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Parent/Guardian Name(s)
Your answer
Phone Number(s) *
Your answer
Email(s) *
Your answer
Address *
Your answer
Learning/Educational Needs (Please list anything we need to know for us to help your child shine their brightest light!)
Your answer
Please include any allergies especially air born all families and faculty need to be aware of (i.e. peanut - when packing snacks).
Your answer
I use an Epi pen and I will bring mine each day to class.
After School Classes: I understand I need to pay my child's tuition, $125 (sliding scale w/ scholarships available), by January 7th. *
Required
I understand I need to provide my child with a healthy snack, water bottle, and tennis shoes each day of class. *
I understand I must pick up my child no later than 5 minutes after class to respect the instructors' and venue's schedule. *
Hold Harmless: I am the parent or guardian of the child named above. I hereby acknowledge that my child could be injured or have an accident while participating in an Arts Class. With this understanding, I hereby consent to allow my child to participate in the Class/Showcase and release Lighthouse Players as well as Madison Middle School (the School Venue) and all instructors, directors, coordinators, spouses or representatives of the above entity from any liability of claims resulting from any accident or injury occurring to my child. I also agree to indemnify and to hold above named parties harmless from any liability and expense from any accident or injury that may occur in any manner in connection with the Classes and Showcases. *
Medical Release: My child, named above, has permission to participate in the current Lighthouse Players: Winter Session of Classes. The following information is provided so that the adult(s) in charge may contact a responsible person in case of illness or accident during the activity. Emergency Contact Name(s) & Phone Number(s), Doctors Name & Phone Number: *
Your answer
My child is in good health and may engage in all activities. *
Please describe any important medical information about your child and list ALL medications taken:
Your answer
Date of last tetanus shot:
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I give my permission for the adult in charge to take my child to a medical facility, if necessary, incase of emergency. If none of the above can be contacted, I consent to treatment for my child under the supervision of, and as deemed advisable, by a physician licensed under the MedicinePractice Act. This provides authority pursuant to Section 25.B of the California Civil Code. *
Permission to Photograph and Videotape: I give permission for my child to be photographed and videotaped for publicity purposes related to Classes and Showcase. I understand that my child’s photo may appear in the newspaper or on the Lighthouse Players' website or on the company's or instructors’ Facebook or Instagram. *
What is your experience in Musical Theatre: Acting, Singing, Dancing? First timers welcome! *
Your answer
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