YPT Release Form
Please submit one form for each cast member.
CLASS MEMBER INFORMATION
Class Member's First Name *
Your answer
Class Member's Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Class Member's Email Address (optional)
Your answer
Class Member's Cell Phone (XXX) XXX-XXXX (optional)
Your answer
Birthdate *
MM
/
DD
/
YYYY
Age *
Your answer
Grade (Fall 2018) *
Your answer
PARENT INFORMATION
Parent #1 First Name *
Your answer
Parent #1 Last Name *
Your answer
Parent #1 Cell Phone # (XXX) XXX-XXXX *
Your answer
Parent #1 Home Phone # (XXX) XXX-XXXX
Your answer
Parent #1 Work Phone # (XXX) XXX-XXXX
Your answer
Parent #1 Email Address *
Your answer
Parent #1 Home Address (Street, City, State, Zip) *
Your answer
Parent #2 First Name
Your answer
Parent #2 Last Name
Your answer
Parent #2 Cell Phone # (XXX) XXX-XXXX
Your answer
Parent #2 Home Phone # (XXX) XXX-XXXX
Your answer
Parent #2 Work Phone # (XXX) XXX-XXXX
Your answer
Parent #2 Email Address
Your answer
Parent #2 Home Address (Street, City, State, Zip)
Your answer
EMERGENCY CONTACTS
Please list two people to contact in case you can't be reached in an emergency situation.
Emergency Contact Person #1: First and Last Name *
Your answer
Emergency Contact Person #1: Cell Phone Number (XXX) XXX-XXXX *
Your answer
Emergency Contact Person #1: Other Phone Number (XXX) XXX-XXXX (Optional)
Your answer
Emergency Contact Person #2: First and Last Name *
Your answer
Emergency Contact Person #2: Cell Phone Number (XXX) XXX-XXXX *
Your answer
Emergency Contact Person #2: Other Phone Number (XXX) XXX-XXXX (Optional)
Your answer
HEALTH AND MEDICAL INFORMATION
Please list any medication(s) that your young person is taking. YPT does not dispense medication. Please note if your young person has medication for self-use and if refrigeration is required. If no medications, list "none."

Please list any allergies that your young person has including medication, food, animals, or others. Do any require an EpiPen? If no allergies, list "none."

Please list any conditions that may prevent your young person from participating in any physical activity. If no limitations, list "none."

Medications *
Your answer
Allergies *
Your answer
Conditions *
Your answer
MEDICAL AND INSURANCE INFORMATION
Health Insurance Carrier *
Your answer
Health Insurance Group/Policy Number *
Your answer
Hospital Preference *
Your answer
Physician's Name *
Your answer
Physician's Phone # (XXX) XXX-XXXX *
Your answer
Dentist's Name *
Your answer
Dentist's Phone Number (XXX) XXX-XXXX *
Your answer
AUTHORIZATION FOR MEDICAL TREATMENT
I understand that in case of serious accident or illness involving a young person while s/he is in the custody of Young People's Theater or its employees, every effort will be made to contact the parent or guardian. I also understand that a situation may arise when emergency treatment may be necessary and the parent or guardian cannot be reached. By entering my name in the field below, I hereby confirm that I am the young person's parent/legal guardian and authorize YPT personnel to make provisions for treatment with the appropriate medical personnel or facility in such situations.
Parent/Guardian Full Name *
Your answer
YPT RELEASE FORM
By entering my name in the field below, I hereby confirm that I am the young person's parent/legal guardian and that I understand the risks of illness and injury inherent in any theater program and I am allowing my young person to participate under the express agreement and understanding that I am hereby releasing Young People's Theater, its directors, teachers, employees, and agents from and against any and all claims, costs, liabilities, expenses, and judgments arising out of my young person's participation in Young People's Theater's programs, or any illness or injury resulting therefrom. I also understand that photographs taken may appear on the official YPT website (www.youngpeoplestheater.com) and/or YPT's Instagram and Facebook pages.
Parent/Guardian Full Name *
Your answer
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