Fall '18 Production Registration
Fall 2018 Production
Email address *
Student Name (First, Last) *
Your answer
Birth Date *
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DD
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YYYY
Grade *
Your answer
Gender *
Home Address *
Your answer
Mailing Address *
Your answer
PARENT/GUARDIAN INFORMATION
Name (First, Last) *
Your answer
Daytime Phone *
Your answer
Evening Phone *
Your answer
Cell Phone
Your answer
Email *
Your answer
EMERGENCY INFORMATION
Emergency Contact Name (First, Last) *
Your answer
Relationship
Your answer
Phone Number *
Your answer
Alt Phone Number
Your answer
Emergency Contact #2 Name (First, Last) *
Your answer
Phone Number *
Your answer
Alt Phone Number
Your answer
Please list any current medications, medical conditions, recent injuries, and food, drug or other allergies:
Your answer
IF MAILING A CHECK MAKE ALL CHECKS PAYABLE TO:
Arizona Rose Youth Theatre
MAIL TO: PO Box 2031 Cortaro, AZ 85652 .

All payments are final.
Parents may be asked to assist in supplying a costume for their child for the final production
Additional rehearsals may be scheduled the week prior to the final presentation at no additional charge.
Please keep this in mind when scheduling

Payment Method *
Informed Consent and Acknowledgement
I (we) hereby release, forever discharge and agree to hold harmless The Arizona Rose Theatre Co., its principals, employees, agents and assigns, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the undersigned’s child(ren) that occur while they are participating in any classes or activities conducted by The Arizona Rose Theatre Co. The undersigned further hereby agrees to hold harmless and indemnify The Arizona Rose Theatre Co., its principals, employees and agents for any liability sustained by said participant, including expenses incurred attendant thereto. The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify The Arizona Rose Theatre Co., its directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant. *
Permission to Video and Photograph
I hereby grant permission for my child to be video recorded and/or photographed while participating in programs and activities of Arizona Rose Theatre Company. It is my understanding that video and photographs will be used for educational, training and promotional purposes only. I may revoke this permission at ant time be sending a letter to Arizona Rose Theatre Company *
Confirmation
BY ACKNOWLEDGING AND SUBMITTING FORM, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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