Registration form - Alfred University

ALFRED UNIVERSITY THEATER WORKSHOP REGISTRATION FORM
(Please print clearly. If you are registering more than one child, please make
as many copies of this form as you need so you can use a separate form for each child.)
Name:__________________________________________Age/Grade_______________
male
female
Address:_______________________________________Phone:__________________Birthdate:_________
School:____________________________ Workshop(s) you are registering for: Theater I
Theater I&II
HEALTH HISTORY & EMERGENCY INFORMATION
Personal Medical History: Has he/she had any of the following? Please check all that are applicable.
Anemia
Kidney Disease
Vision Problems
Asthma
Hepatitis
Malignancy
Hay Fever
Chicken Pox
Operations
Hives
Measles
Scarlet Fever
Other:_________
Mumps
Ear Infections
Bronchitis
______________
Tonsillitis
Heart Problems
Rheumatic Fever
______________
Pneumonia
Arthritis
Psychiatric Care
Epilepsy
Emotional Disorders
Diabetes
Tuberculosis
Mononucleosis
Jaundice
Allergies: Any allergies yes no
If yes, what is he/she allergic to?:______________________________________________________________________
___________________________________________________________________
EMERGENCY INFORMATION:
Parents’/Guardian’s Name(s)___________________________________Daytime phone:__________________________
Home Phone:______________________Cell Phone:________________________ E-mail:_________________________
Please list an additional person to contact in case of an emergency if the parent or guardian cannot be reached:
Name:______________________________________________________ Relationship to Student:___________________
Home/Cell Phone:_________________________Work Phone:________________________ email:___________________
Student’s Regular Physician (primary care provider):__________________________________Phone:_________________
Health Insurance Information (If possible, please enclose a photo copy of your insurance card):
Name of person listed as primary insured on the insurance card:_________________________________________________
Insurance Company:______________________________________________ Policy Number:________________________
Are there any special precautions that must be considered in treating the participant in the case of an emergency
(allergies, diabetes, contact lenses, etc.)?
yes
no If yes, please explain:
Important! Please turn this sheet over and complete reverse side.
Permission to Attend Camp, be Photographed & to Receive Medical Treatment
 I, the undersigned parent or guardian, do hereby grant permission for my son/daughter,
_________________________________, to participate in a summer program at Alfred University.
 I give permission for my son/daughter to be photographed while participating in camp activities for publicity
purposes (some photos will be selected for use on our website and flyers): yes
no
 I do hereby grant permission for my son/daughter ____________________________, to receive
necessary medical treatment in the event of injury or illness while attending a summer program at
Alfred University. I accept responsibility for full payment of such medical treatment. I will not hold
the University, the Student Health Center, hospital, and/or their representatives responsible in the
exercise of this authority.
_________________________________________
SIGNATURE of parent or guardian
_____________________________________
PRINT name of parent or guardian
Payment
Return this registration form and your payment by June 20th to:
Alfred University
Division of Performing Arts
attn: Becky Prophet
Saxon Drive, Alfred, NY 14802.
Make checks payable to “Alfred University.”
Questions? Call 607-871-2255 or email: [email protected]
(Note: Faculty and Staff of Alfred University are entitled to a discount of $15 per child, per workshop.)