A or B A or B A or B TOTAL $ BRING completed form with payment

2015 CHILDREN’S SUMMER WORKSHOP REGISTRATION FORM
CIRCLE PREFERRED Workshop
Workshop A July 20 – Aug 1
Workshop B Aug 3 – 15
(Brief audition 7/19)
(Brief audition 8/2)
Workshop space is limited and will be filled on a first-come, first-served basis.
Name
Gender
School
Date of Birth
M F
/
/
M F
/
/
M F
/
/
Grade
T-shirt Size
(in Fall 2015)
YM
AS
YM
AS
YM
AS
YL(10-12) YXL
AM AL AXL
YL(10-12) YXL
AM AL AXL
YL(10-12) YXL
AM AL AXL
Circle Preferred
Workshop
Fee
A or B
$ 275
A or B
$ 225
A or B
$ 225
TOTAL $
MAIN HOUSEHOLD CONTACT (please print)
Name
E-mail__
________
Street Address ________________________________________________________________ City
Home Phone (___________)____________--____________________
EMERGENCY MEDICAL INFORMATION
EMERGENCY CONTACT
State _____ Zip
Mobile Phone (___________)____________--____________________
Participant’s Doctor
Phone: (______)_______-
Participant’s Dentist
Phone: (______)_______Relationship
Phone: (______)_______-
List any health problems, medications, allergies or special needs or circumstances:
LIABILITY WAIVER FOR PARTICIPANT/GUARDIAN: In consideration of your accepting my or my child’s entry, I hereby, for myself, my child, my heirs, executors, and administrators, waive and
release any and all rights and claims for damages I or my child may have against the Aurora Community Theatre, its representatives, successors and assigns for any and all injuries suffered by myself or my child on any
activity sponsored by these groups. I do hereby grant the right for my child(ren) to be photographed at Aurora Community Theatre for purposes of publicity and promotion including press releases and ACT-produced
newsletters, brochures and all printed materials, as well as video and audio recording. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the Aurora Community Theatre harmless of
and from any and all liability of whatever nature which may arise out of or result from such uses. For the consideration stated above, I further agree that in the event that my child repudiates or attempts to repudiate such
release, I will personally indemnify and save harmless the Aurora Community Theatre, its successors and assigns, for any and all loss and damage occasioned hereby.
Parent/Guardian Signature:
Date: _____/_____/_______
BRING completed form with payment to OPEN REGISTRATION April 30, 2015 between 6 and 8 pm
Make checks payable to Aurora Community Theatre
OR Visa MC Disc Amex ________________________________________________________exp ___________ cvv________ Signature____________________________________
After April 30: Mail to Aurora Community Theatre PO Box 9 Aurora, Ohio 44202
No refunds will be given after June 1, 2015
FOR OFFICE USE ONLY: PMD____________#___________ CK #________________________ CK AMT ____________________ CK Date____________________