IN THE SCENE, BEHIND THE SCENES: Techniques in Experimental Film and Theatre (Ages 10 to 13) Spring Break Camp 2019 Registration/Permission Form
Your registration for the Light House Studio/Live Arts Spring Break camp is not complete until you have both purchased the camp through the Live Arts ticketing website, and filled out this form. Please type your name at the end of the form as your signature to confirm your responses to each question.
Liability Release Form *
*My child has my permission to participate in the Live Arts/ Light House Studio Spring Break Camp. I understand that I am responsible for any damage to property or persons resulting from my child's actions. I understand that consumption or possession of alcohol or illegal drugs is not permitted. I give permission for Live Arts and/or Light House Studio staff to call for emergency medical services in the event that I or the emergency contact person cannot be reached and before contacting me if the Live Arts/Light House Studio personnel deem it appropriate. I hereby release and agree to indemnify and hold harmless Light House Studios and Live Arts, its agents, employees, officers, and directors from any and all responsibilities and liability for injuries to my child (children) while he/she is enrolled in a Light House Studio/Live Arts Workshop.
Name of Child (Children) registered *
Your answer
Age of child (children) *
Your answer
Name of Parent or Guardian *
Your answer
Relationship to child (children) *
Your answer
Home # *
Your answer
Work # *
Your answer
Cell # *
Your answer
Email *
Your answer
Emergency Authorization and Consent for Spring Break Camp *
I/We undersigned parents or legal guardians of the minor(s) registered do hereby give authorization and consent for medical treatment in the event my child becomes ill or injured during a Light House Studio/Live Arts Workshop. Light House Studio and Live Arts Staff or Volunteers are authorized to take one or more of the following actions: a) provide reasonable basic first aid; b) release my child to the person listed below; c) take my child to a physician or call the physician indicated; or, d) take my child to the hospital and/or give consent for emergency care.
Person in addition to parent or guardian to contact in emergency (and relationship to minor) *
Your answer
Home # *
Your answer
Work # *
Your answer
Cell # *
Your answer
Doctor's Name *
Your answer
Doctor's Office Address *
Your answer
Doctor's Phone # *
Your answer
Please indicate any significant health history of which Light House/Live Arts should be aware
Your answer
Please list all allergies and/or medications *
Your answer
Are there any other issues or special needs that we should be aware of?
Your answer
What would your child most like to get out of the Spring Break Camp experience?
Your answer
By typing my name at the end of this form, I agree to the following: *
A. Medical Release: I hereby certify my son(s) and/or daughter(s) are in good health and may participate in all activities.
By typing my name at the end of this form, I agree to the following: *
B. Off-Site Release: My child (children) has my permission to leave the main workshop location (Light House Studio at Vinegar Hill Theatre (220 W. Market Street) and Live Arts (123 E. Water St, SE)) under the supervision of Light House Studio and Live Arts mentors, staff or enrolled volunteers, to participate in workshop activities off grounds.
By typing my name at the end of this form, I agree to the following: *
C. Enrollment Agreement: Light House Studio and/or Live Arts reserves the right to dismiss any student who it determines in conduct, industry, or progress proves unsafe or disruptive to the goals of any given workshop.
Media Release Form *
I hereby permit Light House Studio to use, in whole or in part, photos, videos, written extractions and voice recordings of my child (children) for the purpose of illustrations, publications, media relations and film festivals. By signing this document, I assign to Light House all rights, title, and interest, including, for example, copyright, moral rights, rights of attribution, and other rights of ownership, in and to the photos, videos, written extractions and voice recordings and all materials resulting therefrom. I agree that Light House owns all rights in and to the photos, videos, written extractions and voice recordings and that Light House may obtain in its name a copyright in any materials or production of the photos, videos, written extractions and voice recordings.
Lunch on the Mall Day Permission *
Most days of camp, each student will bring a bagged lunch from home to eat at Live Arts or Light House, Vinegar Hill. However, we may have one "Lunch on the Mall Day," during which the campers will go to selected restaurants with a camp counselor to purchase lunch with money they bring in from home. The students will eat their lunches on the Downtown Mall at the Pavilion on this day, weather permitting. Please indicate your preference below:
Sign In/Sign Out *
Please indicate your preference
Signature *
Please type your name as your signature in agreement and understanding of all sections described above.
Your answer
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