EMERGENCY/WAIVER

Emergency Information (Please type or print clearly)

Childs Name:
________________________________________________________________________
Nickname: ______________________________________________
Age: _____________ DOB: _____________
Address:
_____________________________________________________________________________
City/Town: ________________________________ Zip: _________
Home Tel: _________________________
Grade: ____________
Parent or Guardian Information
Name(s):
_____________________________________________________________________________
Cell Phone ____________________________________
Work Phone________________________________
EMAIL:
_______________________________________________________________________________
Emergency Contact Persons: (Friend or relative, other than parent, who could
come to take your child in case of illness or other emergency when we cannot reach
you)
Name: ______________________________________
Relationship to Child: _________________________
Home Tel: ________________________
Cell: _______________________
Work: ____________________
Address:
____________________________________________________________________________
____________________________________________________________________________________

Emergency Medical Conditions: (allergies, medication etc.)

_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Information Which will Help us to get to Know Your Child: (use
back if you like)
_____________________________________________________________________________________
_______________ _____________________________________________________________________
WAIVER
I understand that The Fundamentals of Acting is not responsible for illness or
injuries affecting my child (childs name) _____________________________, nor for
his/her possessions, while participating in the class; I release The Fundamentals of
Acting from any such responsibility and waive any claims against The Fundamentals
of Acting and its directors, instructors, and volunteers in this regard.
You hereby give permission to The Fundamentals of Acting Theater to use (childs
name) ____________________, portrait, video image or voice recording for the purpose
of fundraising, advertising, and promoting performances and the organization.
___NO ___YES
___Yes with these restrictions: ___________________________________________________
Parents Signature: __________________________________________________
Date: _____________________
Print Name:
__________________________________________________________________________