| Child #1 Name: |
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| Child #1 Age: |
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| School Attending (or Home School): |
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| Child #2 Name: |
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| Child #2 Age: |
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| School Attending or (Home School): |
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| Parents' or Guardians' Names: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Emergency Contact Information: |
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| Do we have your most up to date Emergency Contact Information already on file?: |
If we do, you may submit now,
If not, please conitinue. |
| Emergency Contact Name: |
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| Emergency Contact Phone Number: |
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| Name of Child's/Children's Doctor: |
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| Doctor's Phone Number: |
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| Name of Insurance Carrier: |
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| Child's/Children's First Name followed by his/her Medical Record Number: |
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| Are there any allergies, medications, injuries, or medical conditions we or an emergency care provider should know about?: |
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| Vaudevillians Stage Troupe Policy: |
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| I, the parent or guardian of the minor(s) named above, agree to allow my child to participate in the Vaudevillians Stage Troupe class and or workshop that he/she has registered. In consideration for and as a condition of participation, I agree to indemnify and hold harmless Vaudevillians Stage Troupe and its staff, officers and directors from and against any and all liability from actions resulting in injury associated with my child’s participation in the activities related to the classes and programs. I understand and am familiar with the nature of activities in which my child will be participating. My child is in good physical health and does not have any physical health conditions or emotional conditions, of which I am aware, which in any way may adversely affect his/her ability to participate in these activities: |
Please Initial
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| I understand that disruptive or disrespectful behavior can affect the experience of the class or workshop and I will do my best to assist my child and the directors with any difficulties. If there is a problem that cannot be solved, I understand that my child could be asked to leave the camp without refund.: |
Please Initial
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I understand that my child may be traveling both in vans and in public transportation (city bus line 7 and bart). We will also be walking through neighborhoods and spending time in public parks. Children will always wear seat belts when travelling in vans.
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Please Initial |
| Vaudevillians Stage Troupe has absolute rights and permission to publish and/or copyright photographs of myself and/or my child. These photographs will be used for marketing and publicity purposes without compensation to myself and/or my child. I hereby waive any right to inspect and approve the finished product: |
Please Initial
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| Please note, Vaudevillians Stage Troupe and our teaching artists are unable to take care of children after the camp has ended. To ensure their safety, children need to be picked up promptly. (Please let Sarita know if you will be needing after care and a fee will be arranged). |
Please Initial
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