Some Theatre Company Summer Academy Consent/Release Form

Some Theatre Company Summer Academy
Consent/Release Form for Summer Program Participants. Each summer program participant must complete this form,
individually, and have the signature of a parent or legal guardian before s/he may participate in theatre
production/performance and camp activities. All sections must be completed. Please print legibly and use a black or blue
ink pen.
Participant Information
Last Name ________________________________ First Name __________________________________________
Date of Birth ________________________________ Age ______________________ Sex ____________________
Home Address: ________________________________________________________________________________
City ___________________________________ State _______________________ Zip ______________________
Home Phone ( ) _______________________________ Cell Phone ( ) _______________________________
In Case of Emergency
Person #1 _____________________________________________________________________________________
Relationship _______________________________ Cell Phone ( )_____________________________________
Phone (day) ( ) _____________________________ Phone (night) ( ) __________________________________
Person #2 _____________________________________________________________________________________
Relationship _______________________________ Cell Phone ( )_____________________________________
Phone (day) ( ) _____________________________ Phone (night) ( ) ___________________________________
Medical Profile
Generally, my health is (check one) __________ Excellent ___________ Good __________ Fair __________ Poor
If fair or poor, please explain your condition: _______________________________________________________
List any medical difficulties for which you are currently being treated: ____________________________________
List any medications you are currently taking: ________________________________________________________
LIST ANY ALLERGIES ____________________________________________________________________________
DO YOU CARRY AN EPI-PEN? _____________________________________________________________________
Family Physician ____________________________________________ Phone ( )_______________________
Physician Address ______________________________________________________________________________
Insurance Company: ___________________________________________ Phone ( )______________________
Policy number _________________________________________________________________________________
Authorization for Medical Treatment
For myself and/or on behalf of my participating child/grandchild, I hereby give permission for any physician, hospital, or
health care facility to provide medical care, treatment, and administer medication to participant as deemed necessary
by a physician or STC Summer Academy.
Release of All Claims
For and in consideration of participation in STC Summer Academy, I hereby acknowledge that we understand that there
could be some risks involved, and we hereby assume all such risks. I hereby release Some Theatre Company and all of its
agents, employees, officers, and directors from any and all risks, actions, causes of action, claims, demands, liabilities
and obligations of any and every nature whatsoever, including, without limitation, for illness, personal injury, death,
property damage, and personal or proprietary rights, and hereby hold Some Theatre Company harmless and agree to
fully indemnify Some Theatre Company from and against any and all claims. I hereby personally assume full
responsibility for any and all claims and for any and all hospital and medical bills for myself and/or participant. I hereby
certify to Some Theatre Company that I have obtained and will maintain in full force and effect adequate primary
medical insurance for myself and/or participant. In the event it is necessary for me or participant to return home due to
disciplinary action, for medical reasons, or otherwise, I hereby personally assume full responsibility for all such
transportation arrangements and costs.
Parent/Legal Guardian Signature______________________________Student Signature_______________________
Consent to Use and Publication of Image
I hereby give STC Summer Academy the absolute, unconditional, and irrevocable right and permission to use my name
and Participant’s name and to use, reproduce, edit, exhibit, project, display, copyright, and publish, photographic images
and/or moving pictures and/or videotape images of me and/or Participant, with or without voice, in which I and/or
Participant are included, in whole or in part, photographed, taped, videotaped, and/or recorded prior to, during and/or
after the theatrical event and to circulate same in any and all forms and media for art and advertising, and I hereby
consent to the use of all printed matter in conjunction therewith and waive all rights to inspect and/or approve drafts,
finished products, and/or editorial, promotional, and printed copy and sound tracks that may be used in connection
therewith, and waive all rights to control any aspect of any production, alteration, use, distribution or disposition of said
products, copy, and/or sound tracks, and hereby discharge and agree to Some Theatre Company harmless and fully
indemnify Some Theatre Company from and against any and all claims arising by virtue of any blurring, distortion,
alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in
the production, processing, duplication, projecting, or displaying of said images of me and/or Participant, and from any
and all claims for violation of any personal and all proprietary rights me or the Participant may have or may claim to
have in connection with such images and with the production, alteration, use, distribution, and disposition thereof.
Please complete and sign below
Participant’s Signature: ______________________________________________ Date ___________________
Parent/Custodial Signature______________________________________________Date ___________________
Phone: ( )__________________________________________________________________________________