IYT/IYT JR Registration

IYT/IYT JR 2022-2023 SEASON WORKSHOP REGISTRATION

Date (required)

Actor Name (Last Name, First Name)(required)

Age

Birthday

Parent/Guardian Name(required)

MAILING ADDRESS

Street (Mailing) Address(required)

City(required)

State(required)

Zip Code(required)

CONTACT INFORMATION

Parent/Guardian Email(required)

Parent/Guardian Phone Number(required)

Actor Email

Actor Phone Number

IYT WORKSHOPS (GR 8-12) CHOOSE

FALL WORKSHOP $395.00 WINTER WORKSHOP $495.00 WINTER WORKSHOP DANCER ONLY $350.00 SPRING WORKSHOP (Gr 3-12) $395.00 SUMMER WORKSHOP $695.00

IYT JR WORKSHOPS (GR 3-7) CHOOSE

FALL WORKSHOP $395.00 WINTER WORKSHOP $395.00 SPRING WORKSHOP (Gr 3-12) $395.00 SUMMER WORKSHOP $595.00

HEALTH HISTORY INFORMATION

Because performance can be a highly physical activity, it is necessary that the following information concerning health history be provided. Please remember that all information is considered important and confidential.

EMERGENCY CONTACT – Enter name, relationship, and phone number

LIST ANY KNOWN ALLERGIES

LIST ANY CURRENT CONDITIONS BEING MONITORED BY A PHYSICIAN and any special instructions in the event of a health crisis

General Release/Indemnification

In case of an emergency, if the staff of Gary Taylor Dance/Imagine Youth Theater is unable to reach me by phone, concerning a situation that requires immediate emergency medical assistance, I hereby give my permission to the staff to secure treatment for my child as named in this application. As an additional consideration, I release Gary Taylor Dance/Imagine Youth Theater from liability for injuries to the person or property of the student, which may occur while participating in the activities of this company. In addition, I will not hold Gary Taylor Dance/Imagine Youth Theater responsible for any theft, accident or injury during any Gary Taylor Dance/Imagine Youth Theater function or activity.

Gary Taylor Dance/Imagine Youth Theater shall have the right to use the name, photograph, video-tape, voice, or other likeness of the student; and to exhibit the same through any medium whatsoever during the term of this agreement or at any time in the future for advertising, promotional or commercial purposes. All such reproduction shall be the exclusive property of Gary Taylor Dance/Imagine Youth Theater.

CERTIFICATION

By submitting this form, I understand that I am registering for a workshop and committing to the fees. I also certify that the above information is accurate and complete and I am in agreement with this release and consider it legal and binding: TYPE NAME:

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